Provider Demographics
NPI:1588679898
Name:JELLICO COMMUNITY HOSPITAL INC.
Entity Type:Organization
Organization Name:JELLICO COMMUNITY HOSPITAL INC.
Other - Org Name:JELLICO COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHULAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-1334
Mailing Address - Street 1:PO BOX 844869
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4869
Mailing Address - Country:US
Mailing Address - Phone:423-784-1334
Mailing Address - Fax:423-784-1336
Practice Address - Street 1:188 HOSPITAL LAN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-1334
Practice Address - Fax:423-784-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000007282NR1301X, 282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN397905000OtherFEDERAL BLACK LUNG
TN440180OtherTC AMBULANCE
TN54976OtherONE NATION OLD ANTHEM BE
TN1530476OtherUNITED MINE WORKERS
TN440180OtherMEDICARE MANAGED CARE
TNA3776201OtherTC AMBULANCE
TNA3776201OtherJOHN DEERE COMMERCIAL
TN55620496OtherUNISYS AMBULANCE
TN6530360OtherAETNA
TN0440180Medicaid
KY162084800Medicaid
TN1000250OtherBLUE CROSS BLUE SHIELD TN
TN450003829OtherKY MEDICAID EPSDT
TN54976OtherANTHEM BLUE CROSS
TN440180Medicare Oscar/Certification
TN397905000OtherFEDERAL BLACK LUNG
TN450003829OtherKY MEDICAID EPSDT
TN6530360OtherAETNA
TN=========OtherBLUEGRASS FAMILY HEALTH
TNA3776201OtherTC AMBULANCE
KY162084800Medicaid