Provider Demographics
NPI:1245399534
Name:GALLATIN RURAL HEALTH CLINIC
Entity type:Organization
Organization Name:GALLATIN RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ITAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-253-8863
Mailing Address - Street 1:232 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62984
Mailing Address - Country:US
Mailing Address - Phone:618-269-3139
Mailing Address - Fax:618-269-3057
Practice Address - Street 1:232 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:SHAWNEETOWN
Practice Address - State:IL
Practice Address - Zip Code:62984
Practice Address - Country:US
Practice Address - Phone:618-269-3139
Practice Address - Fax:618-269-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE85295Medicare UPIN
ILK12411Medicare ID - Type Unspecified