MEDICARE: NORTHERN ILLINOIS HOSPICE ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	2000313	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9579	OTHER	ID	BLUECROSS/BLUESHIELD PROV

General Provider Information

NPI Number	:	1700884731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN ILLINOIS HOSPICE ASSOCIATION

Provider Business Mailing Address
First Line	:	4751 HARRISON AVE
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-7929
Country	:	US
Telephone Number	:	815-398-0500
Fax Number	:	815-398-0588

Provider Business Practice Location Address
First Line	:	4751 HARRISON AVE
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-7929
Country	:	US
Telephone Number	:	815-398-0500
Fax Number	:	815-398-0588

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. LISA J NOVAK
Credential	:
Telephone Number	:	815-398-0500

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	04/02/2025

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