1891023164 NPI number — ILLINOIS DEPARTMENT OF PUBLIC HEALTH

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 1891023164 NPI number — ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
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:
1891023164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 WEST JEFFERSON
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-524-5983
Provider Business Mailing Address Fax Number:
217-524-6090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 WEST JEFFERSON
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-524-5983
Provider Business Practice Location Address Fax Number:
217-524-6090
Provider Enumeration Date:
11/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
HIV/AIDS ASSISTANT SECTION CHIEF
Authorized Official Telephone Number:
217-782-1207

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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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