Provider Demographics
NPI:1174796734
Name:MADISON COUNTY URBAN LEAGUE
Entity type:Organization
Organization Name:MADISON COUNTY URBAN LEAGUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WALKINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-876-9145
Mailing Address - Street 1:PO BOX 135
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IL
Mailing Address - Zip Code:62060-0135
Mailing Address - Country:US
Mailing Address - Phone:618-876-9145
Mailing Address - Fax:618-452-5392
Practice Address - Street 1:500 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IL
Practice Address - Zip Code:62060-1414
Practice Address - Country:US
Practice Address - Phone:618-876-9145
Practice Address - Fax:618-452-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid