=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376313791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST BERNARD HOSPITAL & HEALTH CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2024
-----------------------------------------------------
Last Update Date | 01/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 326 W 64TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60621-3146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 177-396-2404
-----------------------------------------------------
Fax | 773-962-4098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 809642
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60680-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-410-1171
-----------------------------------------------------
Fax | 630-410-1171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ROBERT C SPRINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-962-4210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------