Healthcare Provider Details

I. General information

NPI: 1689717126
Provider Name (Legal Business Name): HINES VA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 06/16/2008
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 Number194.001696
License Number StateIL

VIII. Authorized Official

Name: GRANT WAMACK
Title or Position: RRT
Credential:
Phone: 708-202-8387