Basic Information
Provider Information | |||||||||
NPI: | 1619143997 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GLENBROOK HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: | ROOM 1223 | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701644 | ||||||||
FaxNumber: | 8477335315 | ||||||||
Practice Location | |||||||||
Address1: | 2650 RIDGE AVE | ||||||||
Address2: | ROOM 1223 | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701644 | ||||||||
FaxNumber: | 8477335315 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2008 | ||||||||
LastUpdateDate: | 05/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEST | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | EDWARD | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 8476575815 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EVANSTON NORTHWESTERN HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | P.A. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 085000949 | IL | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.