Basic Information
| Provider Information | |||||||||
| NPI: | 1407889652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVENTIST MIDWEST HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTHEALTH 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: | 7083521200 | ||||||||
| FaxNumber: | 6303127975 | ||||||||
| Practice Location | |||||||||
| Address1: | 5101 WILLOW SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605252600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083521200 | ||||||||
| FaxNumber: | 6303127975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STILL | ||||||||
| AuthorizedOfficialFirstName: | DANAE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6308566001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVENTIST MIDWEST HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0005017 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 364257550001 | 01 | IL | CHAMPUS | OTHER | 140065 | 01 | IL | UNICARE | OTHER | 140065 | 01 | IL | STERLING PLAN | OTHER | 364257550001 | 05 | IL | MEDICAID | 399 | 01 | IL | BLUE CROSS | OTHER |