Basic Information
Provider Information | |||||||||
NPI: | 1265454391 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRESENCE CENTRAL AND SUBURBAN HOSPITALS NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRESENCE MERCY MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1325 N HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605061449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6308592222 | ||||||||
FaxNumber: | 6308599014 | ||||||||
Practice Location | |||||||||
Address1: | 1325 N HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605061449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6308592222 | ||||||||
FaxNumber: | 6308599014 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARTER | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
AuthorizedOfficialTitleorPosition: | AMITA CFO | ||||||||
AuthorizedOfficialTelephone: | 2242732350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | ID NUMBER 0004903 | IL | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 1012 | 05 | IL |   | MEDICAID |