Provider Demographics
NPI:1982746640
Name:COUNTY OF MADISON
Entity Type:Organization
Organization Name:COUNTY OF MADISON
Other - Org Name:MADISON COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PUBLIC HEALTH ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LEHP
Authorized Official - Phone:618-296-6065
Mailing Address - Street 1:101 E EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1369
Mailing Address - Country:US
Mailing Address - Phone:618-296-6065
Mailing Address - Fax:618-296-7011
Practice Address - Street 1:101 E EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1369
Practice Address - Country:US
Practice Address - Phone:618-296-6065
Practice Address - Fax:618-296-7011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0433473OtherCLIA NUMBER
IL=========002Medicaid
IL=========002Medicaid