Provider Demographics
NPI:1255453056
Name:CENTRAL PROFESSIONAL GROUP
Entity type:Organization
Organization Name:CENTRAL PROFESSIONAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEVIDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-725-6511
Mailing Address - Street 1:210 N HAMMES AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6680
Mailing Address - Country:US
Mailing Address - Phone:815-725-6511
Mailing Address - Fax:815-725-7166
Practice Address - Street 1:210 N HAMMES AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6680
Practice Address - Country:US
Practice Address - Phone:815-725-6511
Practice Address - Fax:815-725-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1467473462Medicaid
IL1467473462Medicaid
IL260039635Medicare PIN
ILK51874Medicare PIN
IL=========Medicare UPIN
IL145247Medicare PIN
IL145029Medicare PIN
IL145221Medicare PIN
IL14S213Medicare PIN
IL260040422Medicare PIN
IL145316Medicare PIN
IL145372Medicare PIN
IL145754Medicare PIN
IL260050585Medicare PIN
ILK51496Medicare PIN
IL=========OtherMEDICARE RAILROAD
IL145710Medicare PIN
IL260019863Medicare PIN
ILCL4519Medicare PIN
ILL26936Medicare PIN
IL140213Medicare PIN
IL1467473462Medicaid
IL145311Medicare PIN
IN145761Medicare PIN
IL800009300Medicare PIN
IL145694Medicare PIN
IL211727Medicare PIN
IL800009299Medicare PIN
IL80009298Medicare PIN
IL145618Medicare PIN
IL260025882Medicare PIN
IL1417197690Medicare PIN
IL1184648248Medicare PIN