Provider Demographics
NPI:1699794578
Name:JELLICO COMMUNITY HOSPITAL INC.
Entity type:Organization
Organization Name:JELLICO COMMUNITY HOSPITAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHULAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-1334
Mailing Address - Street 1:PO BOX 844869
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4869
Mailing Address - Country:US
Mailing Address - Phone:423-784-1334
Mailing Address - Fax:423-784-1336
Practice Address - Street 1:188 HOSPITAL LANE
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-1334
Practice Address - Fax:423-784-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000007275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01620848Medicaid
TN1000250OtherBLUE CROSS BLUE SHIELD
TN1530476OtherUNITED MINE WORKERS
TNA3776201OtherJOHN DEERE COMMERCIAL
TN0440180Medicaid
TN1000250OtherTC AMBULANCE
TN6530360OtherAETNA
TNA3776201OtherTC AMBULANCE
TN397905000OtherFEDERAL BLACK LUNG
TN440180OtherMEDICARE MANAGED CARE
TN440180OtherTC AMBULANCE
TN54976OtherANTHEM BLUE CROSS
TN55620496OtherUNISYS AMBULANCE
TNA3776201OtherTC AMBULANCE
TN397905000OtherFEDERAL BLACK LUNG
TN440180OtherTC AMBULANCE
TN=========Other1 POINT SOLUTIONS
FL44U180Medicare Oscar/Certification
TN55620496OtherUNISYS AMBULANCE
TN6530360OtherAETNA