Basic Information
| Provider Information | |||||||||
| NPI: | 1265776793 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH CHICAGO VA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2246104070 | ||||||||
| FaxNumber: | 2246103706 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2246104070 | ||||||||
| FaxNumber: | 2246103706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2246104176 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VETERANS ADMINISTRATION | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | OC003528L | PA | N | Hospitals | General Acute Care Hospital | 286500000X | 056.005664 | IL | Y | Hospitals | Military Hospital |
No ID Information.