NPIMap

Organization Active NPI

Illinois Medicaid-Substance Abuse Macomb

  • Substance Use Disorder Rehabilitation Clinic/Center
  • Macomb, IL
National Provider Identifier
1588032460
Registry record updated Aug 19, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Substance Use Disorder Rehabilitation Clinic/CenterTaxonomy code 261QR0405X
Legal business name
ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB
Practice address
900 S Deer Rd
Macomb, IL 61455-2639
Phone
(309) 837-4876
NPI assigned
Sep 9, 2015
Last updated
Aug 19, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
BRIDGEWAY INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 19, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Bill A Nelson, LCPC
Title
Ceo
Phone
(309) 344-4200

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Methadone Clinic 261QM2800X NU
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X IL Primary
Addiction (Substance Use Disorder) Counselor 101YA0400X A-0118-0010-A IL
Psychiatry Physician 2084P0800X IL
Child & Adolescent Psychiatry Physician 2084P0804X IL

Addresses

Primary practice location

900 S Deer Rd
Macomb, IL 61455-2639

Mailing address

900 S Deer Rd
Macomb, IL 61455-2639
Phone (309) 837-4876

National Provider Directory

National Provider Directory
Tax ID family
Julio R Lozano MD15 organizations share this tax ID, including this one
Part of
Julio R Lozano MD

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1566172800000",
    "number": "1588032460",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "900 S DEER RD",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614552639",
            "telephone_number": "309-837-4876"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 S DEER RD",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614552639",
            "telephone_number": "309-837-4876"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ILLINOIS MEDICAID-SUBSTANCE ABUSE MACOMB",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BRIDGEWAY INC",
        "enumeration_date": "2015-09-09",
        "last_updated": "2019-08-19",
        "status": "A",
        "authorized_official_last_name": "NELSON",
        "authorized_official_first_name": "BILL",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "309-344-4200",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LCPC"
    },
    "taxonomies": [
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "IL",
            "license": null,
            "primary": true
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "IL",
            "license": "A-0118-0010-A",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "IL",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Macomb, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.