Provider Demographics
NPI:1629056056
Name:ANDERSON HOSPITAL
Entity Type:Organization
Organization Name:ANDERSON HOSPITAL
Other - Org Name:ANDERSON HOME HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:ENGELKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-635-4242
Mailing Address - Street 1:6800 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-9355
Mailing Address - Fax:618-288-6978
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-9355
Practice Address - Fax:618-288-6978
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDERSON HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-05
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1004019251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370662561003Medicaid
IL=========003Medicaid