Basic Information
| Provider Information | |||||||||
| NPI: | 1790750016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALOS COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PALOS COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15295 E. 127TH STREET | ||||||||
| Address2: | |||||||||
| City: | LEMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302571111 | ||||||||
| FaxNumber: | 6302571115 | ||||||||
| Practice Location | |||||||||
| Address1: | 15295 E. 127TH STREET | ||||||||
| Address2: | |||||||||
| City: | LEMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302571111 | ||||||||
| FaxNumber: | 6302571115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOISAN | ||||||||
| AuthorizedOfficialFirstName: | TERRENCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089235000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1008069 | IL | Y | Agencies | Home Health |
No ID Information.