Provider Demographics
NPI:1740834233
Name:MERIDIAN HEALTH PLAN OF ILLINOIS, INC.
Entity type:Organization
Organization Name:MERIDIAN HEALTH PLAN OF ILLINOIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-206-3252
Mailing Address - Street 1:8735 HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1143
Mailing Address - Country:US
Mailing Address - Phone:813-206-3252
Mailing Address - Fax:
Practice Address - Street 1:300 S RIVERSIDE PLZ STE 500
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-6641
Practice Address - Country:US
Practice Address - Phone:813-206-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLCARE OF MICHIGAN HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization