Provider Demographics
NPI:1710975842
Name:SOUTHGATE HEALTH CARE CENTER, INC
Entity Type:Organization
Organization Name:SOUTHGATE HEALTH CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-524-2683
Mailing Address - Street 1:900 E 9TH ST
Mailing Address - Street 2:PO BOX 843
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2700
Mailing Address - Country:US
Mailing Address - Phone:618-524-2683
Mailing Address - Fax:618-524-3048
Practice Address - Street 1:900 E 9TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2700
Practice Address - Country:US
Practice Address - Phone:618-524-2683
Practice Address - Fax:618-524-3048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0017996314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
50044OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid
50044OtherBLUE CROSS BLUE SHIELD