Provider Demographics
NPI:1649210444
Name:PASSAVANT MEMORIAL AREA HOSPITAL
Entity Type:Organization
Organization Name:PASSAVANT MEMORIAL AREA HOSPITAL
Other - Org Name:THE CENTER FOR PSYCHIATRIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-479-5527
Mailing Address - Street 1:PO BOX 1977
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62705-1977
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6021
Practice Address - Street 1:557 N WESTGATE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1156
Practice Address - Country:US
Practice Address - Phone:217-245-7275
Practice Address - Fax:217-245-7427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06932018OtherBLUE CROSS BLUE SHIELD
ILCB3741OtherRAILROAD MEDICARE
IL681484OtherHEALTHLINK PROVIDER #
IL681484OtherHEALTHLINK PROVIDER #
IL210873Medicare ID - Type UnspecifiedMEDICARE GROUP #