Provider Demographics
NPI:1710946801
Name:RED BUD ILLINOIS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:RED BUD ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:RED BUD NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE OP/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3840
Mailing Address - Street 1:PO BOX 503891
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W SOUTH 1ST ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1116
Practice Address - Country:US
Practice Address - Phone:618-282-3891
Practice Address - Fax:618-282-4070
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED BUD ILLINOIS HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-20
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045476313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145309Medicare Oscar/Certification