Provider Demographics
NPI:1851828198
Name:HEARTLAND ALLIANCE HEALTH
Entity Type:Organization
Organization Name:HEARTLAND ALLIANCE HEALTH
Other - Org Name:HEARTLAND HEALTH OUTREACH, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STELLON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:312-405-0802
Mailing Address - Street 1:4750 N SHERIDAN RD STE 435
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5078
Mailing Address - Country:US
Mailing Address - Phone:773-751-4129
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:5501 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2229
Practice Address - Country:US
Practice Address - Phone:773-275-2586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-17
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251B00000X
251S00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid