Provider Demographics
NPI:1366550055
Name:LAWRENCE COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:LAWRENCE COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-843-8424
Mailing Address - Street 1:2111 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-2085
Mailing Address - Country:US
Mailing Address - Phone:618-943-1000
Mailing Address - Fax:618-943-7223
Practice Address - Street 1:2111 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-2085
Practice Address - Country:US
Practice Address - Phone:618-943-1000
Practice Address - Fax:618-943-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14Z344275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0212OtherBLUE CROSS BLUE SHILED
IL5115002OtherBLUE CROSS BLUE SHILED
IL108986OtherHEALTHLINK
IL005219OtherHEALTH ALLIANCE
IL5115002OtherBLUE CROSS BLUE SHILED