Basic Information
| Provider Information | |||||||||
| NPI: | 1366718918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HSHS HOLY FAMILY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREENVILLE OBSTETRICS AND GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HEALTHCARE DRIVE | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186649830 | ||||||||
| FaxNumber: | 6186649820 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEALTHCARE DRIVE | ||||||||
| Address2: | STE 1501 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622461154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186641230 | ||||||||
| FaxNumber: | 6186642424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | ENNEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6186641230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0005355 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.