Basic Information
| Provider Information | |||||||||
| NPI: | 1487981916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVOCATE HEALTH AND HOSPITALS CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVOCATE BROMENN REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1304 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617613558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1304 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617613558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNT | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO - BROMENN MEDICAL CTR | ||||||||
| AuthorizedOfficialTelephone: | 3094540700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1932356 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 376073462001 | 05 | IL | MEDICAID |