Basic Information
| Provider Information | |||||||||
| NPI: | 1366487936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVENTIST HEALTH PARTNERS, INC | ||||||||
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| OtherOrganizationName: | ADULT MEDICINE PHYSICIANS OF COUNTRYSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6438 JOLIET RD | ||||||||
| Address2: | |||||||||
| City: | COUNTRYSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605254685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083525222 | ||||||||
| FaxNumber: | 7083525285 | ||||||||
| Practice Location | |||||||||
| Address1: | 6438 JOLIET RD | ||||||||
| Address2: | |||||||||
| City: | COUNTRYSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605254685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083525222 | ||||||||
| FaxNumber: | 7083525285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 06/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | RUBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 6308566884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.