Basic Information
| Provider Information | |||||||||
| NPI: | 1841333788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LITTLE COMPANY OF MARY HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LCMH MOBILE MEDICAL PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 SOUTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082294663 | ||||||||
| FaxNumber: | 7084995975 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 SOUTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082294663 | ||||||||
| FaxNumber: | 7084995975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREYER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7082295004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0161859661 | 01 | IL | BCBS OF IL | OTHER | CC0511 | 01 | IL | RR MEDICARE | OTHER |