=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144216474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JAMES HOSPTIAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 OTTO BLVD
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-709-2165
-----------------------------------------------------
Fax | 708-709-2027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 747
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60412-0747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-709-2165
-----------------------------------------------------
Fax | 708-709-2027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL CFO
-----------------------------------------------------
Name | MR. THOMAS W SENESAC
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 708-756-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------