Provider Demographics
NPI:1356596563
Name:CHESTNUT HEALTH SYSTEMS INC
Entity type:Organization
Organization Name:CHESTNUT HEALTH SYSTEMS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:309-820-3535
Mailing Address - Street 1:1003 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1429
Mailing Address - Country:US
Mailing Address - Phone:309-827-6026
Mailing Address - Fax:
Practice Address - Street 1:1003 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1429
Practice Address - Country:US
Practice Address - Phone:309-827-6026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0126-0002-A251S00000X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC/A-0126-0007-AMedicaid