Basic Information
| Provider Information | |||||||||
| NPI: | 1760415939 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVENTIST GLENOAKS HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVENTHEALTH GLENOAKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 701 WINTHROP AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601391405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305458000 | ||||||||
| FaxNumber: | 6303127975 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 WINTHROP AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601391405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305458000 | ||||||||
| FaxNumber: | 6303127975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8475902496 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 003814 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 90 | 01 | IL | BLUE CROSS | OTHER | 140292 | 01 | IL | UNICARE | OTHER | 140292 | 01 | IL | STERLING | OTHER |