Provider Demographics
NPI:1356365670
Name:ALTON MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:ALTON MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-463-7301
Mailing Address - Street 1:11133 DUNN RD
Mailing Address - Street 2:PFD 2ND FLOOR SUITE 2179
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6119
Mailing Address - Country:US
Mailing Address - Phone:314-653-4093
Mailing Address - Fax:314-653-4077
Practice Address - Street 1:1251 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6735
Practice Address - Country:US
Practice Address - Phone:618-463-7330
Practice Address - Fax:618-463-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0008409314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
46497OtherGHP
0000000709OtherBLUE CROSS BLUE SHIELD
7100035OtherUNITED HEALTHCARE
=========OtherCIGNA
=========OtherGREAT WEST HEALTHCARE
=========OtherTRICARE
0000000709OtherBLUE CROSS BLUE SHIELD
46497OtherGHP
7100035OtherUNITED HEALTHCARE
=========OtherHEALTHLINK
=========OtherMERCY
E00=========OtherAETNA