=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659740033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESENCE HOSPITALS PRV
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2015
-----------------------------------------------------
Last Update Date | 09/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 MADISON ST SUITE 302
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-405-6285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10330 W ROOSEVELT RD SUITE 200
-----------------------------------------------------
City | WESTCHESTER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60154-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-405-6285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RFO
-----------------------------------------------------
Name | DEBORAH SCHIMEROWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-337-2740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0205X
-----------------------------------------------------
Taxonomy Name | Pediatric Endocrinology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------