Healthcare Provider Details

I. General information

NPI: 1073283198
Provider Name (Legal Business Name): CHILDRENS ILLINOIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD STE 120
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

1 CHILDRENS PL STE 3S-36
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELE MCKEE
Title or Position: VICE PRESIDENT
Credential:
Phone: 314-454-6044