Basic Information
| Provider Information | |||||||||
| NPI: | 1649515735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE HOLY FAMILY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | HOLY FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOLLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142499 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N. RIVER ROAD | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600160000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472971800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2012 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | WICKLIFFE-JONES | ||||||||
| AuthorizedOfficialFirstName: | MELVONNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MGR | ||||||||
| AuthorizedOfficialTelephone: | 6309142417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 056007151 | IL | N | Hospitals | Long Term Care Hospital | 282E00000X | Y | Hospitals | Long Term Care Hospital |
No ID Information.