MEDICARE: COUNTY OF GREENE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP0905X	State or Local Public Health Clinic/Center

General Provider Information

NPI Number	:	1538829726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF GREENE

Provider Business Mailing Address
First Line	:	310 5TH ST
Second Line	:
City	:	CARROLLTON
State	:	IL
Zip	:	62016-1325
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 5TH ST
Second Line	:
City	:	CARROLLTON
State	:	IL
Zip	:	62016-1325
Country	:	US
Telephone Number	:	217-942-6961
Fax Number	:

Authorized Official
Title or Position	:	FINANCIAL MANAGER
Name	:	JAMIE L WAGNER
Credential	:
Telephone Number	:	217-942-6961

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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Directions to “COUNTY OF GREENE ” Practice Location

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