Basic Information
| Provider Information | |||||||||
| NPI: | 1215943576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVENTIST HEALTH PARTNERS,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTIST MIDWEST GERIATRICS SPECIALISTS LA GRANGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5101 WILLOW SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605252600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082454073 | ||||||||
| FaxNumber: | 7082455614 | ||||||||
| Practice Location | |||||||||
| Address1: | 5101 WILLOW SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605252600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082454073 | ||||||||
| FaxNumber: | 7082455614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | RUBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6308566884 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | CN4921 | 01 | IL | RRMC | OTHER |