Provider Demographics
NPI:1265601488
Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Entity type:Organization
Organization Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-490-1737
Mailing Address - Street 1:1100 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-1429
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1845
Practice Address - Street 1:1100 BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1429
Practice Address - Country:US
Practice Address - Phone:815-490-1601
Practice Address - Fax:815-490-1625
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRUSADERS CENTRAL CLINIC ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
103436OtherDORAL
027548OtherCHAMPUS
1011514778OtherBLUE CROSS BLUE SHIELD
1011514778OtherBLUE CROSS BLUE SHIELD
141847Medicare Oscar/Certification
685940Medicare PIN