Provider Demographics
NPI:1831185156
Name:KATHERINE SHAW BETHEA HOSPITAL-DME
Entity type:Organization
Organization Name:KATHERINE SHAW BETHEA HOSPITAL-DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-285-5511
Mailing Address - Street 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-288-5531
Mailing Address - Fax:
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:815-288-5531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000497282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherEMPLOYER ID NUMBER
IL2581940001Medicare NSC