Provider Demographics
NPI:1336181544
Name:DANVILLE POLYCLINIC, LTD
Entity Type:Organization
Organization Name:DANVILLE POLYCLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-477-4750
Mailing Address - Street 1:707 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-446-6410
Mailing Address - Fax:217-477-4757
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-446-6410
Practice Address - Fax:217-477-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060000812261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100002020AMedicaid
221069OtherBLACK LUNG
IL09215807OtherBCBS OF ILLINOIS
1486765OtherUMWA
=========OtherPREFERRED PLAN
=========OtherPHCS
=========OtherBEECHSTREET
=========OtherCIGNA
1486765OtherUMWA
IN100002020AMedicaid
221069OtherBLACK LUNG
=========OtherHEALTH ALLIANCE
=========OtherPERSONAL CARE/COVENTRY
=========OtherCIGNA
=========OtherHEALTH ALLIANCE
=========OtherPHCS
IL09215807OtherBCBS OF ILLINOIS