Provider Demographics
NPI:1700063179
Name:RICHLAND MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:RICHLAND MEMORIAL HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-395-7340
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-0097
Mailing Address - Country:US
Mailing Address - Phone:618-395-7340
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-7340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050750207Y00000X
IL036060342208600000X
IL036119328208800000X
IL209004125363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08022315OtherBLUE SHIELD
IL216183Medicare PIN