Provider Demographics
NPI:1649453283
Name:MADISON PARK CHRISTIAN CHURCH
Entity type:Organization
Organization Name:MADISON PARK CHRISTIAN CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREACHING MINISTER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:D MIN
Authorized Official - Phone:217-222-2529
Mailing Address - Street 1:4700 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9112
Mailing Address - Country:US
Mailing Address - Phone:217-222-2529
Mailing Address - Fax:217-222-2895
Practice Address - Street 1:4700 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9112
Practice Address - Country:US
Practice Address - Phone:217-222-2529
Practice Address - Fax:217-222-2895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001320049OtherBLUE CROSS/BLUE SHIELD
IL344905000OtherMAGELLAN HEALTH SERVICES