Basic Information
| Provider Information | |||||||||
| NPI: | 1124322680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JAMES HOSPITAL UNITED STATES CATHOLIC CONFERENCE | ||||||||
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| OtherOrganizationName: | ST JAMES FRANCISCAN MEDICAL PAVILION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 W 203RD ST | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087096295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2010 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | SENESAC | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7087561000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.