Healthcare Provider Details

I. General information

NPI: 1104262377
Provider Name (Legal Business Name): PRESENCE SAINT JOSEPH HOSPITAL-ELGIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 N AIRLITE ST
ELGIN IL
60123-4912
US

IV. Provider business mailing address

1000 REMINGTON BLVD STE 100
BOLINGBROOK IL
60440-5114
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-3200
  • Fax:
Mailing address:
  • Phone: 630-914-2417
  • Fax: 630-914-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-006950
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209008175
License Number StateIL

VIII. Authorized Official

Name: MELVONNE JONES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-914-2417