Provider Demographics
NPI:1033404363
Name:INTERACTIVE HEALTHCARE OF CENTRAL ILLINOIS
Entity Type:Organization
Organization Name:INTERACTIVE HEALTHCARE OF CENTRAL ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-344-7930
Mailing Address - Street 1:1701 S 1ST AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-2442
Mailing Address - Country:US
Mailing Address - Phone:708-344-7930
Mailing Address - Fax:708-344-7932
Practice Address - Street 1:1701 S 1ST AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2442
Practice Address - Country:US
Practice Address - Phone:708-344-7930
Practice Address - Fax:708-344-7932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011482251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health