Provider Demographics
NPI:1497123509
Name:ILLINOIS MEDICAID-SUBSTANCE ABUSE GALESBURG
Entity type:Organization
Organization Name:ILLINOIS MEDICAID-SUBSTANCE ABUSE GALESBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-344-4200
Mailing Address - Street 1:2323 WINDISH DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-9780
Mailing Address - Country:US
Mailing Address - Phone:309-344-4200
Mailing Address - Fax:309-344-4281
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-4200
Practice Address - Fax:309-344-4281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGEWAY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-04
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0118-0005-A101YA0400X
261QM2800X, 261QM2800X
IL261QR0405X, 2084P0804X, 251S00000X, 261QM0801X, 276400000X, 324500000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility