1215141627 NPI number — PRESENCE HOSPITALS PRV

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215141627 NPI number — PRESENCE HOSPITALS PRV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESENCE HOSPITALS PRV
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215141627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W COURT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-937-2490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PROVENA WAY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914-4796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-937-8780
Provider Business Practice Location Address Fax Number:
815-937-8241
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FILER
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
SYSTEM, CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
708-478-7674

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  0004879 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0004621885 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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