Provider Demographics
NPI:1891023164
Name:ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:HIV/AIDS SECTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HIV/AIDS ASSISTANT SECTION CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-782-1207
Mailing Address - Street 1:525 WEST JEFFERSON
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62761
Mailing Address - Country:US
Mailing Address - Phone:217-524-5983
Mailing Address - Fax:217-524-6090
Practice Address - Street 1:525 WEST JEFFERSON
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62761
Practice Address - Country:US
Practice Address - Phone:217-524-5983
Practice Address - Fax:217-524-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory