Provider Demographics
NPI:1457337016
Name:FREEPORT REGIONAL HEALTH CARE FOUNDATION
Entity Type:Organization
Organization Name:FREEPORT REGIONAL HEALTH CARE FOUNDATION
Other - Org Name:FHN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-6769
Mailing Address - Street 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4008
Mailing Address - Country:US
Mailing Address - Phone:815-599-7925
Mailing Address - Fax:815-599-7923
Practice Address - Street 1:1036 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4865
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, RadiationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08923833OtherBLUE CROSS
IL582630Medicare PIN
IL08923833OtherBLUE CROSS
IL207602Medicare PIN
IL433440Medicare PIN