1811229693 NPI number — PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER

Table of content: (NPI 1811229693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811229693 NPI number — PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER
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:
1811229693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 REMINGTON BOULEVARD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-914-2417
Provider Business Mailing Address Fax Number:
630-914-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 N WESTERN AVE
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-332-2226
Provider Business Practice Location Address Fax Number:
773-276-1197
Provider Enumeration Date:
02/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WICKLIFFE-JONES
Authorized Official First Name:
MELVONNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MGR
Authorized Official Telephone Number:
630-914-2417

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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