Provider Demographics
NPI:1053467050
Name:CARLE FOUNDATION HOSPITAL
Entity Type:Organization
Organization Name:CARLE FOUNDATION HOSPITAL
Other - Org Name:CARLE RX EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TONKINSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:217-383-3441
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2906
Mailing Address - Fax:217-326-2996
Practice Address - Street 1:311 W FAIRCHILD ST
Practice Address - Street 2:SUITE B
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3876
Practice Address - Country:US
Practice Address - Phone:217-431-7975
Practice Address - Fax:217-431-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054012046333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1448679OtherNABP ID NUMBER
IL=========012Medicaid
IL=========012Medicaid