Basic Information
| Provider Information | |||||||||
| NPI: | 1528402518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADDUS HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WARRENVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602963400 | ||||||||
| FaxNumber: | 6304872713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 FORT ST STE 0 | ||||||||
| Address2: | |||||||||
| City: | BARLING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729232045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794522652 | ||||||||
| FaxNumber: | 4794522084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | AR4955 | AR | N | Agencies | Home Health | 253Z00000X | AR4955 | AR | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | 197330752 | 05 | AR | MEDICAID | 200410732 MAPC | 05 | AR | MEDICAID | 197328757 | 05 | AR | MEDICAID | 197329797 | 05 | AR | MEDICAID | 197325796 | 05 | AR | MEDICAID |