Provider Demographics
NPI:1831634237
Name:CHESTNUT HEALTH SYSTEMS, INC
Entity type:Organization
Organization Name:CHESTNUT HEALTH SYSTEMS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF CFHC
Authorized Official - Prefix:
Authorized Official - First Name:DIETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KULICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-557-1437
Mailing Address - Street 1:1003 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1429
Mailing Address - Country:US
Mailing Address - Phone:309-827-6026
Mailing Address - Fax:
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-397-0900
Practice Address - Fax:618-397-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care