Provider Demographics
NPI:1528106812
Name:COUNTY OF MENARD
Entity type:Organization
Organization Name:COUNTY OF MENARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-632-3283
Mailing Address - Street 1:1120 N 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675-1115
Mailing Address - Country:US
Mailing Address - Phone:217-632-3283
Mailing Address - Fax:217-632-3675
Practice Address - Street 1:1120 N 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-1115
Practice Address - Country:US
Practice Address - Phone:217-632-3283
Practice Address - Fax:217-632-3675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MENARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid