Basic Information
| Provider Information | |||||||||
| NPI: | 1548392541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOREST PARK, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PAVILLION OF FOREST PARK, L.L.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8200 ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | FOREST PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601302528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084889850 | ||||||||
| FaxNumber: | 7084889870 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | FOREST PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601302528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084889850 | ||||||||
| FaxNumber: | 7084889870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEINBERG | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8479053000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0043778 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 364186094001 | 05 | IL | MEDICAID | 1192 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |