=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891023164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS DEPARTMENT OF PUBLIC HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2009
-----------------------------------------------------
Last Update Date | 11/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 WEST JEFFERSON 1ST FLOOR
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-524-5983
-----------------------------------------------------
Fax | 217-524-6090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 WEST JEFFERSON 1ST FLOOR
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-524-5983
-----------------------------------------------------
Fax | 217-524-6090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HIV/AIDS ASSISTANT SECTION CHIEF
-----------------------------------------------------
Name | MR. MATT CHARLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-782-1207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------