Provider Demographics
NPI:1538444906
Name:MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Entity type:Organization
Organization Name:MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-930-2283
Mailing Address - Street 1:205 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1921
Mailing Address - Country:US
Mailing Address - Phone:217-839-7820
Mailing Address - Fax:217-839-1538
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1473
Practice Address - Country:US
Practice Address - Phone:217-839-1526
Practice Address - Fax:217-839-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL007261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141154OtherNGS MEDICARE
IL=========007Medicaid