Healthcare Provider Details

I. General information

NPI: 1609144815
Provider Name (Legal Business Name): CHESTNUT HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NORTHGATE INDUSTRIAL DR
GRANITE CITY IL
62040
US

IV. Provider business mailing address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-4420
  • Fax: 618-877-0904
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberA-0126-0001-A
License Number StateIL

VIII. Authorized Official

Name: MEGAN MARIE TAYLOR
Title or Position: MANAGED CARE SUPERVISOR
Credential:
Phone: 888-924-3786