Provider Demographics
NPI:1013372440
Name:ADVENTIST BOLINGBROOK HOSPITAL
Entity Type:Organization
Organization Name:ADVENTIST BOLINGBROOK HOSPITAL
Other - Org Name:ADVENTHEALTH BOLINGBROOK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-245-2211
Mailing Address - Street 1:PO BOX 7009
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-7009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4906
Practice Address - Country:US
Practice Address - Phone:630-312-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVENTIST BOLINGBROOK HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-30
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5496273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14S304Medicare PIN