Provider Demographics
NPI:1043323793
Name:VETERAN'S ADMINISTRATION
Entity Type:Organization
Organization Name:VETERAN'S ADMINISTRATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:THORNHILL
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:217-875-2670
Mailing Address - Street 1:632 E BODMAN ST
Mailing Address - Street 2:
Mailing Address - City:BEMENT
Mailing Address - State:IL
Mailing Address - Zip Code:61813-1206
Mailing Address - Country:US
Mailing Address - Phone:217-620-8891
Mailing Address - Fax:
Practice Address - Street 1:3035 E MOUND RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9650
Practice Address - Country:US
Practice Address - Phone:217-875-2670
Practice Address - Fax:217-875-2689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)