Basic Information
| Provider Information | |||||||||
| NPI: | 1497829899 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS HEALTH ASSOCIATION OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 N 1ST STREET | ||||||||
| Address2: | BOX 136 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882882 | ||||||||
| FaxNumber: | 2177577550 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627814026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882882 | ||||||||
| FaxNumber: | 2177577550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | KOS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | IPA ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2175882674 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.