Provider Demographics
NPI:1720453202
Name:STREATOR CHIDLRENS CLINIC
Entity Type:Organization
Organization Name:STREATOR CHIDLRENS CLINIC
Other - Org Name:STREATOR CHILDREN'S CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEADY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-2353
Mailing Address - Street 1:111 SPRING ST FL 5
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-3332
Mailing Address - Country:US
Mailing Address - Phone:815-673-2353
Mailing Address - Fax:815-673-2486
Practice Address - Street 1:111 SPRING ST FL 5
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3332
Practice Address - Country:US
Practice Address - Phone:815-673-2353
Practice Address - Fax:815-673-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091951174400000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091951Medicaid
IL036091951Medicaid