Basic Information
| Provider Information | |||||||||
| NPI: | 1316974595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF MORGAN HEALTH DEPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 E STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626502125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172455111 | ||||||||
| FaxNumber: | 2172434773 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 E STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626502125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172455111 | ||||||||
| FaxNumber: | 2172434773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAINTER | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PUBLIC HEALTH ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2172455111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BS | ||||||||
| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | ========= | 05 | IL | MEDICAID |