Provider Demographics
NPI:1912044223
Name:COUNTY OF BUREAU
Entity Type:Organization
Organization Name:COUNTY OF BUREAU
Other - Org Name:BUREAU COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PUBLIC HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-872-5091
Mailing Address - Street 1:526 S BUREAU VALLEY PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2066
Mailing Address - Country:US
Mailing Address - Phone:815-872-5091
Mailing Address - Fax:815-872-5092
Practice Address - Street 1:526 S BUREAU VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2046
Practice Address - Country:US
Practice Address - Phone:815-872-5091
Practice Address - Fax:815-872-5092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL600000324Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL=========002Medicaid