Basic Information
Provider Information | |||||||||
NPI: | 1649830472 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SALEM TOWNSHIP HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STH FAMILY HEALTH CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1201 RICKER RD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | IL | ||||||||
PostalCode: | 628814263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185483194 | ||||||||
FaxNumber: | 6185480167 | ||||||||
Practice Location | |||||||||
Address1: | 1321 W WHITTAKER ST | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | IL | ||||||||
PostalCode: | 628812013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185486644 | ||||||||
FaxNumber: | 8446595619 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2019 | ||||||||
LastUpdateDate: | 08/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NAZARIAN | ||||||||
AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO/CFO | ||||||||
AuthorizedOfficialTelephone: | 6185483194 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SALEM TOWNSHIP HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA, MBA, MHA | ||||||||
NPICertificationDate: | 08/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.