Provider Demographics
NPI:1871704874
Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4101
Mailing Address - Street 1:525 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3313
Mailing Address - Country:US
Mailing Address - Phone:309-833-4101
Mailing Address - Fax:
Practice Address - Street 1:525 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-833-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005519699OtherBLUE SHIELD GROUP
IL794630Medicare ID - Type UnspecifiedMEDICARE GROUP