Basic Information
| Provider Information | |||||||||
| NPI: | 1124253315 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HSHS HOLY FAMILY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GREENVILLE REGIONAL SPECIALTY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HEALTHCARE DR | ||||||||
| Address2: | STE 1501 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
| FaxNumber: | 6186642424 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEALTHCARE DR | ||||||||
| Address2: | STE 1501 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
| FaxNumber: | 6186642424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRACTICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6186903530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.