1427426055 NPI number — CEREBRAL PALSY OF SOUTHWESTERN ILLINOIS

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 1427426055 NPI number — CEREBRAL PALSY OF SOUTHWESTERN ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEREBRAL PALSY OF SOUTHWESTERN ILLINOIS
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:
1427426055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 LINCOLN PLACE CT
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62221-5884
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:
138 LINCOLN PLACE CT
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62221-5884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-0210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HAEGE
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
618-233-0210

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: 199100130S , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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