Basic Information
| Provider Information | |||||||||
| NPI: | 1902170632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORPORATION | ||||||||
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| OtherOrganizationName: | FAIRFIELD COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | |||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628220155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187244628 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 NW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628371218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188424470 | ||||||||
| FaxNumber: | 6188423437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2012 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | MITROKA | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6187242436 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.