Basic Information
Provider Information | |||||||||
NPI: | 1043646177 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADDUS HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADDUS HOMECARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 WARRENVILLE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302963400 | ||||||||
FaxNumber: | 6304872713 | ||||||||
Practice Location | |||||||||
Address1: | 1144 WILLAGILLESPIE RD | ||||||||
Address2: | #32 | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974016729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413425567 | ||||||||
FaxNumber: | 5413425747 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2013 | ||||||||
LastUpdateDate: | 01/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | DARBY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP, CHIEF STRATEGY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6302963591 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADDUS HOMECARE CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | 152234 | OR | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 519011 | 05 | OR |   | MEDICAID |