Provider Demographics
NPI:1851363154
Name:NATIONAL HEALTHCARE OF MT VERNON INC
Entity Type:Organization
Organization Name:NATIONAL HEALTHCARE OF MT VERNON INC
Other - Org Name:CROSSROADS COMMUNITY HOSPITAL
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 60548
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 DOCTORS PARK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6224
Practice Address - Country:US
Practice Address - Phone:618-244-5500
Practice Address - Fax:618-244-5566
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL HEALTHCARE OF MT VERNON INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-02
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0003947275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN14U294Medicare Oscar/Certification