Provider Demographics
NPI:1790941276
Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Other - Org Name:MCDONOUGH DISTRICT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4101
Mailing Address - Street 1:525 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3313
Mailing Address - Country:US
Mailing Address - Phone:309-833-4101
Mailing Address - Fax:309-836-1525
Practice Address - Street 1:525 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-833-4101
Practice Address - Fax:309-836-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1438341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid