Basic Information
| Provider Information | |||||||||
| NPI: | 1528112224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT JOSEPH HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAINT JOSEPH HOSPITAL SKILLED NURSING UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653317 | ||||||||
| FaxNumber: | 7736653460 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 N OAKLEY BLVD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606223507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735728500 | ||||||||
| FaxNumber: | 7735728568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PFISTER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR, PFS | ||||||||
| AuthorizedOfficialTelephone: | 7737929903 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 8000051 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5448 | 01 | IL | BLUE CROSS PROVIDER NUMBE | OTHER |