Provider Demographics
NPI:1598797193
Name:KEWANEE HOSPITAL
Entity Type:Organization
Organization Name:KEWANEE HOSPITAL
Other - Org Name:KEWANEE HOSPITAL FAMILY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-852-7522
Mailing Address - Street 1:P.O. BOX 747
Mailing Address - Street 2:1051 W SOUTH STREET
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-9983
Mailing Address - Country:US
Mailing Address - Phone:309-852-7500
Mailing Address - Fax:309-852-7591
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-9983
Practice Address - Country:US
Practice Address - Phone:309-852-7500
Practice Address - Fax:309-852-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X, 261QR1300X
IL0005538261QM2500X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143445Medicare Oscar/Certification