Healthcare Provider Details

I. General information

NPI: 1447388392
Provider Name (Legal Business Name): MACOUPIN COUNTY PUBLIC HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E MAPLE ST
GILLESPIE IL
62033-1473
US

IV. Provider business mailing address

205 OAKLAND AVE
CARLINVILLE IL
62626-1921
US

V. Phone/Fax

Practice location:
  • Phone: 217-839-4110
  • Fax: 217-839-4105
Mailing address:
  • Phone: 217-839-7820
  • Fax: 217-839-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number005
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. KENT ALAN TARRO
Title or Position: ADMINISTRATOR
Credential:
Phone: 217-854-3223