Provider Demographics
NPI:1912538448
Name:MOLINA HEALTHCARE OF ILLINOIS, INC.
Entity Type:Organization
Organization Name:MOLINA HEALTHCARE OF ILLINOIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, GOVERNMENT CONTRACTS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-203-3982
Mailing Address - Street 1:1520 KENSINGTON RD STE 212
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 KENSINGTON RD STE 212
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2197
Practice Address - Country:US
Practice Address - Phone:888-562-5442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOLINA HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization