Healthcare Provider Details

I. General information

NPI: 1083620827
Provider Name (Legal Business Name): ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 COLLEGE AVE
ALTON IL
62002
US

IV. Provider business mailing address

4500 COLLEGE AVE
ALTON IL
62002-5051
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: TONYA PIEPHOFF
Title or Position: HOSPITAL ADMINISTRATOR
Credential:
Phone: 618-474-3473