Provider Demographics
NPI:1720405301
Name:RESIDENTIAL HOSPICE OF SOUTHERN ILLINOIS, LLC
Entity Type:Organization
Organization Name:RESIDENTIAL HOSPICE OF SOUTHERN ILLINOIS, LLC
Other - Org Name:CELTIC HOSPICE & PALLIATIVE CARE SERVICES OF S. IL, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-283-8839
Mailing Address - Street 1:5440 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2645
Mailing Address - Country:US
Mailing Address - Phone:866-902-4000
Mailing Address - Fax:866-903-4000
Practice Address - Street 1:4215 S STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3267
Practice Address - Country:US
Practice Address - Phone:800-358-8227
Practice Address - Fax:888-229-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-1576Medicare PIN