Provider Demographics
NPI:1982605135
Name:COUNTY OF JO DAVIESS
Entity Type:Organization
Organization Name:COUNTY OF JO DAVIESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:815-777-0263
Mailing Address - Street 1:9483 W US 20
Mailing Address - Street 2:P.O. BOX 318
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-9182
Mailing Address - Country:US
Mailing Address - Phone:815-777-1040
Mailing Address - Fax:815-777-0292
Practice Address - Street 1:9483 W US 20
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-9182
Practice Address - Country:US
Practice Address - Phone:815-777-1040
Practice Address - Fax:815-777-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1494045251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9646OtherBLUE CROSS BLUE SHIELD
ILL031253OtherTRICARE
IL9646OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid