Basic Information
| Provider Information | |||||||||
| NPI: | 1629433784 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SALEM TOWNSHIP HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STH FAMILY HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 RICKER RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628814263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185483194 | ||||||||
| FaxNumber: | 6185480924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 W WHITTAKER ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628812013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185480200 | ||||||||
| FaxNumber: | 6185480924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2015 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6185483194 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SALEM TOWNSHIP HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSN | ||||||||
| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.