Organization
CRUSADERS CENTRAL CLINIC ASSOCIATION
Active
Parent organization
CRUSADERS CENTRAL CLINIC ASSOCIATION
Other names
Crusader Clinic Broadway
Organization subpart
Yes
Provider details
NPI number
Legal business name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Authorized official
SAMUEL MILLER (PRESIDENT & CEO)
(815) 490-1737
Entity
Organization
Contact information
Practice address
1100 BROADWAY, ROCKFORD, IL 61104-1429
(815) 490-1601
(815) 490-1625
Mailing address
1100 BROADWAY, ROCKFORD, IL 61104-1429
(815) 490-1600
(815) 490-1845
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
027548
CHAMPUS
—
01
—
1011514778
BLUE CROSS BLUE SHIELD
—
01
—
103436
DORAL
—
Enumeration date
02/21/2008
Last updated
08/24/2022
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