Basic Information
| Provider Information | |||||||||
| NPI: | 1891755351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THOREK MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THOREK MEMORIAL HOSPITAL DBA METHODIST HOSPITAL OF CHICAGO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5025 N PAULINA ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606402772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732719040 | ||||||||
| FaxNumber: | 7732712010 | ||||||||
| Practice Location | |||||||||
| Address1: | 5025 N PAULINA ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606402772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732719040 | ||||||||
| FaxNumber: | 7732712010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUDD | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7739756705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0000125 | IL | N | Hospital Units | Psychiatric Unit | 282N00000X | 0000125 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 362012788001 | 05 | IL | MEDICAID | 362012788002 | 05 | IL | MEDICAID |