Provider Demographics
NPI:1366693632
Name:CHAMPAIGN URBANA PUBLIC HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:CHAMPAIGN URBANA PUBLIC HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM ADMINITRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-531-5369
Mailing Address - Street 1:201 W KENYON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7807
Mailing Address - Country:US
Mailing Address - Phone:217-531-4279
Mailing Address - Fax:217-531-4333
Practice Address - Street 1:201 W KENYON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7807
Practice Address - Country:US
Practice Address - Phone:217-531-4279
Practice Address - Fax:217-531-4333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEALANT PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251K00000X251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1285832006Medicaid