Provider Demographics
NPI:1497829899
Name:PHYSICIANS HEALTH ASSOCIATION OF ILLINOIS
Entity Type:Organization
Organization Name:PHYSICIANS HEALTH ASSOCIATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IPA ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-588-2674
Mailing Address - Street 1:701 N 1ST STREET
Mailing Address - Street 2:BOX 136
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781
Mailing Address - Country:US
Mailing Address - Phone:217-588-2882
Mailing Address - Fax:217-757-7550
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-4026
Practice Address - Country:US
Practice Address - Phone:217-588-2882
Practice Address - Fax:217-757-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization