Healthcare Provider Details

I. General information

NPI: 1497716922
Provider Name (Legal Business Name): JESSE BROWN VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

1244 BEVERLY DR
LAKE VILLA IL
60046-6408
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-8387
  • Fax:
Mailing address:
  • Phone: 847-265-1654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number StateIL

VIII. Authorized Official

Name: MISS RHETTA TURNER
Title or Position: ADMINISTRATIVE OFFICER, ANESTHESIOL
Credential:
Phone: 312-569-8387