Provider Demographics
NPI:1447382932
Name:MIDWEST NEUROFITNESS
Entity Type:Organization
Organization Name:MIDWEST NEUROFITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAJORITY PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:217-348-1086
Mailing Address - Street 1:PO BOX 584
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-0584
Mailing Address - Country:US
Mailing Address - Phone:217-348-1086
Mailing Address - Fax:217-355-4012
Practice Address - Street 1:313 N MATTIS AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2460
Practice Address - Country:US
Practice Address - Phone:217-348-1086
Practice Address - Fax:217-355-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002663101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01532018OtherBLUE CROSS BLUE SHIELD