Provider Demographics
NPI:1972658789
Name:CARLE FOUNDATION HOSPITAL
Entity Type:Organization
Organization Name:CARLE FOUNDATION HOSPITAL
Other - Org Name:CARLE RX EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TONKINSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:217-383-3441
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2906
Mailing Address - Fax:217-326-2996
Practice Address - Street 1:1001 HEATHER DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-2754
Practice Address - Country:US
Practice Address - Phone:217-586-8474
Practice Address - Fax:217-586-8475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARLE FOUNDATION HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1472428OtherNABP ID NUMBER
IL1472428OtherNABP ID NUMBER
IL=========-61801-11OtherMEDICAID PAYEE NUMBER
IL=========020Medicaid