Healthcare Provider Details

I. General information

NPI: 1164522447
Provider Name (Legal Business Name): PROVIDENT HOSPITAL OF COOK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 51ST ST
CHICAGO IL
60615-2400
US

IV. Provider business mailing address

400 VILLAGE CIR UNIT 110
WILLOW SPRINGS IL
60480-1802
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-1202
  • Fax:
Mailing address:
  • Phone: 708-839-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateIL

VIII. Authorized Official

Name: PAMELA THOMAS - HALL
Title or Position: CFO
Credential:
Phone: 312-572-1202