Basic Information
Provider Information | |||||||||
NPI: | 1962642140 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. JOSEPHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12866 TROXLER AVE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 622492806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186512600 | ||||||||
FaxNumber: | 6186512555 | ||||||||
Practice Location | |||||||||
Address1: | 12866 TROXLER AVE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 622492806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186512600 | ||||||||
FaxNumber: | 6186512555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2009 | ||||||||
LastUpdateDate: | 02/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOSACKA | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6186415468 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.