1063005288 NPI number — SPRINGHEALTH BEHAVIORAL HEALTH AND INTEGRATED CARE ILLINOIS, LLC

Table of content: JAMIE LYNN STOGSDILL APSS (NPI 1972201796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063005288 NPI number — SPRINGHEALTH BEHAVIORAL HEALTH AND INTEGRATED CARE ILLINOIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGHEALTH BEHAVIORAL HEALTH AND INTEGRATED CARE ILLINOIS, LLC
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:
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:
1063005288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 N WHITTINGTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-394-2100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3921 PINTAIL DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62711-6738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-843-0290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MATTINGLY
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MGR PROVIDER ENROLLMENT
Authorized Official Telephone Number:
502-630-7425

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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