Provider Demographics
NPI:1811987134
Name:KATHERINE SHAW BETHEA HOSPITAL
Entity type:Organization
Organization Name:KATHERINE SHAW BETHEA HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHREINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-284-5710
Mailing Address - Street 1:101 W 2ND ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3076
Mailing Address - Country:US
Mailing Address - Phone:815-284-5710
Mailing Address - Fax:815-285-5893
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3116
Practice Address - Country:US
Practice Address - Phone:815-285-5738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001841251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid