Provider Demographics
NPI:1205372778
Name:CHESI MARION CENTRE CLINIC
Entity Type:Organization
Organization Name:CHESI MARION CENTRE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-0450
Mailing Address - Street 1:1250 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5334
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:OFFICE A3
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-734-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH & EMERGENCY SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20164Medicaid
IL20164Medicaid