Provider Demographics
NPI:1538101373
Name:DANVILLE POLYCLINIC, LTD
Entity Type:Organization
Organization Name:DANVILLE POLYCLINIC, LTD
Other - Org Name:DANVILLE POLYCLINIC LTD ASTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-477-4794
Mailing Address - Street 1:707 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4794
Mailing Address - Fax:217-477-4757
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4794
Practice Address - Fax:217-477-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002371261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1525OtherBCBS OF ILLINOIS
167654OtherPERSONAL CARE/COVENTRY
IN200315840AMedicaid
=========002OtherTRICARE/CHAMPUS
IN200315840AMedicaid
IL1525OtherBCBS OF ILLINOIS
IL=========006Medicaid