Healthcare Provider Details

I. General information

NPI: 1669554507
Provider Name (Legal Business Name): PROVIDENT HOSPITAL OF COOK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 51ST ST DEPARTMENT OF GENERAL SURGERY, ROOM 7058
CHICAGO IL
60615-2400
US

IV. Provider business mailing address

500 E 51ST ST DEPARTMENT OF GENERAL SURGERY, ROOM 7058
CHICAGO IL
60615-2400
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-2664
  • Fax: 312-572-2681
Mailing address:
  • Phone: 312-572-2664
  • Fax: 312-572-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001953
License Number StateIL

VIII. Authorized Official

Name: DR. AARON HAMB
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 312-572-2370