Provider Demographics
NPI:1710943907
Name:HAMILTON MEMORIAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:HAMILTON MEMORIAL HOSPITAL DISTRICT
Other - Org Name:HAMILTON MEMORIAL HOSPITAL HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAUBY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
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:618-643-4415
Mailing Address - Fax:618-643-4508
Practice Address - Street 1:112 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1147
Practice Address - Country:US
Practice Address - Phone:618-643-4415
Practice Address - Fax:618-643-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001486251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9705OtherBLUE CROSS BLUE SHIELD
IL9705OtherBLUE CROSS BLUE SHIELD
IL9705OtherBLUE CROSS BLUE SHIELD