Healthcare Provider Details

I. General information

NPI: 1285912337
Provider Name (Legal Business Name): CHESNUT HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 EDISON AVE
GRANITE CITY IL
62040-4513
US

IV. Provider business mailing address

2054 EDISON AVE
GRANITE CITY IL
62040-4513
US

V. Phone/Fax

Practice location:
  • Phone: 618-452-7851
  • Fax:
Mailing address:
  • Phone: 618-452-7851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number04023
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number04023
License Number StateIL

VIII. Authorized Official

Name: MR. ALAN SENDER
Title or Position: C.O.O.
Credential:
Phone: 618-877-4420