Provider Demographics
NPI:1245216241
Name:FULTON COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:FULTON COUNTY HEALTH DEPARTMENT
Other - Org Name:FULTON COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-647-1134
Mailing Address - Street 1:700 EAST OAK STREET
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520
Mailing Address - Country:US
Mailing Address - Phone:309-647-1134
Mailing Address - Fax:309-647-9545
Practice Address - Street 1:700 EAST OAK STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520
Practice Address - Country:US
Practice Address - Phone:309-647-1134
Practice Address - Fax:309-647-9545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULTON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-21
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP0905X
IL261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL328900Medicare ID - Type Unspecified
IL328900Medicare ID - Type Unspecified