Basic Information
| Provider Information | |||||||||
| NPI: | 1083929640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT MARY AND ELIZABETH HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RHS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1404 HACKBERRY RD | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600154021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472360045 | ||||||||
| FaxNumber: | 8472360045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 N OAKLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606223507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127702040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2010 | ||||||||
| LastUpdateDate: | 08/07/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZAMUDIO RASOF | ||||||||
| AuthorizedOfficialFirstName: | SOPHIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY MEDICINE RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8472260821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 125058811 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 125058811 | 01 | IL | ILLINOIS TEMPORARY PHYSICIAN LICENSE | OTHER |