Provider Demographics
NPI:1306279070
Name:HEARTLAND ALLIANCE HEALTH
Entity type:Organization
Organization Name:HEARTLAND ALLIANCE HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STELLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-405-0802
Mailing Address - Street 1:1015 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5017
Mailing Address - Country:US
Mailing Address - Phone:773-751-4129
Mailing Address - Fax:
Practice Address - Street 1:932 W WASHINGTON BLVD FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2217
Practice Address - Country:US
Practice Address - Phone:773-275-2586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND HEALTH OUTREACH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-16
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38369261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306279070Medicaid
IL2283208OtherBUSINESS LICENSE