Provider First Line Business Practice Location Address: 
5000 SOUTH 5TH AVENUE
    Provider Second Line Business Practice Location Address: 
EDWARD HINES, JR. VA HOSPITAL
    Provider Business Practice Location Address City Name: 
HINES
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60141
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-202-8387
    Provider Business Practice Location Address Fax Number: 
708-202-2024
    Provider Enumeration Date: 
03/28/2006