1083620827 NPI number — ILLINOIS DEPARTMENT OF HUMAN SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083620827 NPI number — ILLINOIS DEPARTMENT OF HUMAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS DEPARTMENT OF HUMAN SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083620827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-5051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-474-3800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIEPHOFF
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
Authorized Official Title or Position:
HOSPITAL ADMINISTRATOR
Authorized Official Telephone Number:
618-474-3473

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000194572001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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