Organization
CRUSADERS CENTRAL CLINIC ASSOCIATION
Active
Other names
Crusader Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL MILLER (PRESIDENT & CEO)
(815) 490-1737
Entity
Organization
Contact information
Practice address
1200 W STATE ST, ROCKFORD, IL 61102-2112
(815) 490-1600
Mailing address
1200 W STATE ST, ROCKFORD, IL 61102-2112
(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
—
101-15147-78
BLUE CROSS BLUE SHIELD
—
01
—
101319
DORAL
IL
Enumeration date
11/27/2006
Last updated
08/24/2022
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