Basic Information
Provider Information | |||||||||
NPI: | 1528026168 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3040 W SALT CREEK LN | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600051069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476184604 | ||||||||
FaxNumber: | 8476184630 | ||||||||
Practice Location | |||||||||
Address1: | 3060 W SALT CREEK LN | ||||||||
Address2: | SUITE 110 | ||||||||
City: | ARLINGTON HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600055026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476187800 | ||||||||
FaxNumber: | 8476187809 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 06/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCOGNA | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 8476185017 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1000983 | IL | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 6251175 | 01 | IL | AETNA | OTHER | 9714 | 01 | IL | BLUE CROSS | OTHER |