1457734469 NPI number — VA ILLIANA HEALTHCARE SYSTEM

Table of content: (NPI 1457734469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457734469 NPI number — VA ILLIANA HEALTHCARE SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VA ILLIANA HEALTHCARE SYSTEM
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:
1457734469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 HEDGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61821-2015
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:
1901 E MAIN ST
Provider Second Line Business Practice Location Address:
MAIL SLOT 122
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61832-5117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-554-3755
Provider Business Practice Location Address Fax Number:
217-554-4813
Provider Enumeration Date:
07/08/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
BRYANNA
Authorized Official Middle Name:
ELYCE
Authorized Official Title or Position:
SOCIAL WORKER
Authorized Official Telephone Number:
217-554-3755

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6906-M , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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