Healthcare Provider Details

I. General information

NPI: 1245370907
Provider Name (Legal Business Name): EDWARD HINES VA HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 CAROL ST
PARK RIDGE IL
60068-1205
US

IV. Provider business mailing address

1417 CAROL ST
PARK RIDGE IL
60068-1205
US

V. Phone/Fax

Practice location:
  • Phone: 847-692-1956
  • Fax:
Mailing address:
  • Phone: 847-692-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. BINI ALEX THECCANAT
Title or Position: REGISTERED RESPIRATORY THERAPIST
Credential: RRT
Phone: 708-202-8387