Basic Information
| Provider Information | |||||||||
| NPI: | 1427048826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PA PETERSON CENTER FOR HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476354600 | ||||||||
| FaxNumber: | 8473901426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153998832 | ||||||||
| FaxNumber: | 8153998342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOONDUV | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | EDMUND | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE CFO | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0021238 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0021238 | 05 | IL | MEDICAID |