Provider Demographics
NPI:1447388392
Name:MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3223
Mailing Address - Street 1:805 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1075
Mailing Address - Country:US
Mailing Address - Phone:217-854-3223
Mailing Address - Fax:217-854-3225
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1473
Practice Address - Country:US
Practice Address - Phone:217-839-4110
Practice Address - Fax:217-839-4105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL005251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid