Provider Demographics
NPI:1588032460
Name:ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB
Entity Type:Organization
Organization Name:ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-344-4200
Mailing Address - Street 1:900 S DEER RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2639
Mailing Address - Country:US
Mailing Address - Phone:309-837-4876
Mailing Address - Fax:
Practice Address - Street 1:900 S DEER RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2639
Practice Address - Country:US
Practice Address - Phone:309-837-4876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-09
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0118-0010-A101YA0400X
IL2084P0800X, 2084P0804X, 261QR0405X, 276400000X, 324500000X, 261QR0405X, 261QR0405X
261QM2800X, 261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty
No276400000XHospital UnitsRehabilitation, Substance Use Disorder UnitGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility