Basic Information
| Provider Information | |||||||||
| NPI: | 1528143088 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINDRED THC NORTH SHORE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED - CHICAGO - LAKESHORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6130 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733811222 | ||||||||
| FaxNumber: | 7733810280 | ||||||||
| Practice Location | |||||||||
| Address1: | 6130 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733811222 | ||||||||
| FaxNumber: | 7733810280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6292535121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 4000014 | IL | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 195 | 01 | ID | BLUE CROSS | OTHER | 363915965007 | 05 | IL | MEDICAID | 363915965 | 01 | IL | UNICARE | OTHER |