Healthcare Provider Details

I. General information

NPI: 1336382514
Provider Name (Legal Business Name): EDWARD J. HINES HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

5650 N SHERIDAN RD APT 22C
CHICAGO IL
60660-4879
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-4434
  • Fax: 708-202-4954
Mailing address:
  • Phone: 773-878-8729
  • Fax: 708-202-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number150004789
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number24038
License Number StateIL

VIII. Authorized Official

Name: MISS LOLITA DRUMMOND
Title or Position: SOCIAL WORKER
Credential: MSW, LSW, CADC
Phone: 708-202-4434