Provider Demographics
NPI:1629177910
Name:LAWRENCE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:LAWRENCE COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-943-7202
Mailing Address - Street 1:2200 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-1852
Mailing Address - Country:US
Mailing Address - Phone:618-943-7249
Mailing Address - Fax:618-943-7223
Practice Address - Street 1:2200 STATE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-1852
Practice Address - Country:US
Practice Address - Phone:618-943-7249
Practice Address - Fax:618-943-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL55215341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid
IL=========001Medicaid