Basic Information
| Provider Information | |||||||||
| NPI: | 1831364132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LORETTO HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LORETTO OUTPATIENT MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 645 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606445059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738545000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5120 W JACKSON BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606444332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738545072 | ||||||||
| FaxNumber: | 7732870077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARTMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7738545066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1706406 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.