Provider Demographics
NPI:1568463701
Name:JERSEY COMMUNITY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:JERSEY COMMUNITY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:BEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-498-8300
Mailing Address - Street 1:400 MAPLE SUMMIT RD
Mailing Address - Street 2:PO BOX 426
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2028
Mailing Address - Country:US
Mailing Address - Phone:618-498-6402
Mailing Address - Fax:618-498-8496
Practice Address - Street 1:400 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2028
Practice Address - Country:US
Practice Address - Phone:618-498-6402
Practice Address - Fax:618-498-8496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001156282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL140059Medicare ID - Type Unspecified