Provider Demographics
NPI:1285874529
Name:COUNTY OF WINNEBAGO
Entity type:Organization
Organization Name:COUNTY OF WINNEBAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:MAICHLE
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-720-4210
Mailing Address - Street 1:401 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2014
Mailing Address - Country:US
Mailing Address - Phone:815-720-4000
Mailing Address - Fax:815-720-4001
Practice Address - Street 1:401 DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2014
Practice Address - Country:US
Practice Address - Phone:815-720-4000
Practice Address - Fax:815-720-4001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINNEBAGO COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-26
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0430142251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
329540Medicare UPIN