Healthcare Provider Details

I. General information

NPI: 1285949834
Provider Name (Legal Business Name): EDWARD HINES VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
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

5000 S 5TH AVE
HINES IL
60141-3030
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone: 708-202-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number104100000X
License Number StateIL

VIII. Authorized Official

Name: TONY SPILLIE
Title or Position: SOCIAL WORK EXECUTIVE
Credential: LCSW
Phone: 708-202-2055