Provider Demographics
NPI:1285852772
Name:CARLINVILLE AREA HOSPITAL ASSOCIATION
Entity type:Organization
Organization Name:CARLINVILLE AREA HOSPITAL ASSOCIATION
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:
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3141
Mailing Address - Street 1:20733 N. BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626
Mailing Address - Country:US
Mailing Address - Phone:217-854-3141
Mailing Address - Fax:217-854-9958
Practice Address - Street 1:20733 N. BROAD S
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626
Practice Address - Country:US
Practice Address - Phone:217-854-3141
Practice Address - Fax:217-854-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2024-12-11
Deactivation Date:2023-02-03
Deactivation Code:
Reactivation Date:2024-12-11
Provider Licenses
StateLicense IDTaxonomies
IL0590029483336I0012X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1433224OtherNABP NUMBER
IL370345239001Medicaid