Basic Information
| Provider Information | |||||||||
| NPI: | 1780769257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINDRED THC CHICAGO, LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED HOSPITAL - SYCAMORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601782137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158952144 | ||||||||
| FaxNumber: | 8158957057 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158952144 | ||||||||
| FaxNumber: | 8158957057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 0004945 | IL | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 28 | 01 | IL | BLUE CROSS | OTHER |