Provider Demographics
NPI:1194227827
Name:CHESTNUT HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:CHESTNUT HEALTH SYSTEMS, INC
Other - Org Name:CHESTNUT HEALTH SYSTEMS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-924-3786
Mailing Address - Street 1:1003 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1429
Practice Address - Country:US
Practice Address - Phone:309-826-6026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESNTUT HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-08
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04023261QM0801X, 261QM0801X, 261QM0801X
261QM0850X, 261QM0855X, 320800000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04023Medicaid