Provider Demographics
NPI:1609837665
Name:HAMILTON MEMORIAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:HAMILTON MEMORIAL HOSPITAL DISTRICT
Other - Org Name:HAMILTON MEMORIAL FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-643-2361
Mailing Address - Street 1:611 S MARSHALL AVE
Mailing Address - Street 2:PO BOX 429
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1213
Mailing Address - Country:US
Mailing Address - Phone:618-643-2361
Mailing Address - Fax:618-643-2875
Practice Address - Street 1:611 S MARSHALL AVENUE
Practice Address - Street 2:
Practice Address - City:MCLEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859
Practice Address - Country:US
Practice Address - Phone:618-643-2361
Practice Address - Fax:618-643-2875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000085261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid
IL=========008Medicaid
IL800340Medicare PIN