Provider Demographics
NPI:1861480709
Name:CENTRAL COUNTIES HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:CENTRAL COUNTIES HEALTH CENTERS, INC.
Other - Org Name:CAPITOL COMMUNITY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVANAGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-2300
Mailing Address - Street 1:2239 E COOK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-1944
Mailing Address - Country:US
Mailing Address - Phone:217-788-2300
Mailing Address - Fax:217-788-2343
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:217-788-2300
Practice Address - Fax:217-788-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 122300000X, 207Q00000X, 207R00000X, 208000000X, 363L00000X
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL141897Medicare Oscar/Certification