Basic Information
| Provider Information | |||||||||
| NPI: | 1588856603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELMHURST MEMORIAL HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 172 SCHILLER | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601262885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3312219053 | ||||||||
| FaxNumber: | 6307589940 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 E SCHILLER ST | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601262816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308341120 | ||||||||
| FaxNumber: | 6309935681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | LURYE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3312219053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 2215149 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |