Provider Demographics
NPI:1336216027
Name:ILLINOIS STATE UNIVERSITY
Entity Type:Organization
Organization Name:ILLINOIS STATE UNIVERSITY
Other - Org Name:ISU STUDENT HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:309-438-8258
Mailing Address - Street 1:COLLEGE AND UNIVERSITY
Mailing Address - Street 2:SUITE 2540
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-2540
Mailing Address - Country:US
Mailing Address - Phone:309-438-8258
Mailing Address - Fax:309-438-3689
Practice Address - Street 1:COLLEGE AND UNIVERSITY
Practice Address - Street 2:SUITE 2540
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-2540
Practice Address - Country:US
Practice Address - Phone:309-438-8258
Practice Address - Fax:309-438-3689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service