Basic Information
| Provider Information | |||||||||
| NPI: | 1821462268 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE CHICAGO HOSPITALS NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRESENCE LABOURE OUTPATIENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604405114 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2913 N COMMONWEALTH AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606576211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2015 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | RASMUS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6309142468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.