Basic Information
| Provider Information | |||||||||
| NPI: | 1194480640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE CENTRAL AND SUBURBAN HOSPITALS NETWORK | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMITA SAINT JOSEPH HOSPITAL, ELGIN DIABETIC SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 N AIRLITE STREET | ||||||||
| Address2: | DIABETES SERVICES | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476953200 | ||||||||
| FaxNumber: | 8479315742 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 N AIRLITE STREET | ||||||||
| Address2: | DIABETES SERVICES | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476953200 | ||||||||
| FaxNumber: | 8479315742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MACKNISKAS | ||||||||
| AuthorizedOfficialFirstName: | MARY JO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR, NET REVENUE & REIMB | ||||||||
| AuthorizedOfficialTelephone: | 7732130776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRESENCE CHICAGO HOSPITALS NETWORK | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Health Educator |
No ID Information.