Basic Information
| Provider Information | |||||||||
| NPI: | 1457629966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JAMES HOSPITAL UNITED STATES CATHOLIC CONFERENCE | ||||||||
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| OtherOrganizationName: | FRANCISCAN ST JAMES FAMILY HEALTH CENTER OF CHICAGO HEIGHTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284250 | ||||||||
| FaxNumber: | 3178658316 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E 15TH ST | ||||||||
| Address2: | SUITE # 308 | ||||||||
| City: | CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604113459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087559355 | ||||||||
| FaxNumber: | 7087557851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2011 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | SENESAC | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7087561000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036127750 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.