Basic Information
| Provider Information | |||||||||
| NPI: | 1477598589 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEXIAN BROTHERS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OLDER ADULT HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473646724 | ||||||||
| FaxNumber: | 8473646720 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473646724 | ||||||||
| FaxNumber: | 8473646720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLUMM | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, OLDER ADULT INSTITUTE | ||||||||
| AuthorizedOfficialTelephone: | 8473646724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.