=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235941311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESTNUT HEALTH SYSTEMS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2025
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 337 E FERGUSON AVE
-----------------------------------------------------
City | WOOD RIVER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62095-2003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-877-4420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 MARTIN LUTHER KING DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-924-3786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MEGAN M TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-877-4420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------