Basic Information
| Provider Information | |||||||||
| NPI: | 1629220546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 W RAVINE AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOW SPRINGS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604801455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122066000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 10/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | SIEJA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | NUCLEAR MEDICINE TECHNOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 3122066000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CNMT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 032417 | IL | Y | Hospitals | Military Hospital |
No ID Information.