Basic Information
Provider Information | |||||||||
NPI: | 1518070499 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOTTLIEB MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOTTLIEB HOME HEALTH SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 701 WEST NORTH AVENUE | ||||||||
Address2: |   | ||||||||
City: | MELROSE PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 601601602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7086813200 | ||||||||
FaxNumber: | 7084505058 | ||||||||
Practice Location | |||||||||
Address1: | 905 WEST NORTH AVENUE | ||||||||
Address2: |   | ||||||||
City: | MELROSE PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 601601602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082164983 | ||||||||
FaxNumber: | 7082160808 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2006 | ||||||||
LastUpdateDate: | 04/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIAL | ||||||||
AuthorizedOfficialFirstName: | AJAY | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 7082164252 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GOTTLIEB MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 0005561 | IL | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 9765 | 01 | IL | BLUE CROSS | OTHER |