Provider Demographics
NPI:1104030790
Name:EASTERN ILLINOIS UNIVERSITY HEALTH SERVICE
Entity Type:Organization
Organization Name:EASTERN ILLINOIS UNIVERSITY HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-581-3015
Mailing Address - Street 1:600 LINCOLN AVE
Mailing Address - Street 2:EASTERN ILLINOIS UNIVERSITY
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3011
Mailing Address - Country:US
Mailing Address - Phone:217-581-3015
Mailing Address - Fax:217-581-3899
Practice Address - Street 1:600 LINCOLN AVE
Practice Address - Street 2:EASTERN ILLINOIS UNIVERSITY
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3011
Practice Address - Country:US
Practice Address - Phone:217-581-3015
Practice Address - Fax:217-581-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILE9988478107261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health