Basic Information
Provider Information | |||||||||
NPI: | 1295710580 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MACNEAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3249 OAK PARK AVE | ||||||||
Address2: |   | ||||||||
City: | BERWYN | ||||||||
State: | IL | ||||||||
PostalCode: | 604023429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082160378 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3249 SOUTH OAK PARK AVE | ||||||||
Address2: |   | ||||||||
City: | BERWYN | ||||||||
State: | IL | ||||||||
PostalCode: | 60402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087833125 | ||||||||
FaxNumber: | 7087833166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2005 | ||||||||
LastUpdateDate: | 12/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOLAWOLE | ||||||||
AuthorizedOfficialFirstName: | ADENRELE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR BILLING OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 7082163743 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0005082 | IL | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.