Provider Demographics
NPI:1033290986
Name:PINNACLE HEALTHCARE OF WAUKEGAN
Entity Type:Organization
Organization Name:PINNACLE HEALTHCARE OF WAUKEGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BROSAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-249-2400
Mailing Address - Street 1:1020 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015
Mailing Address - Country:US
Mailing Address - Phone:847-541-9100
Mailing Address - Fax:847-541-9015
Practice Address - Street 1:2222 W 14TH STREET
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-249-2400
Practice Address - Fax:847-249-0536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0044453314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
145669Medicare ID - Type Unspecified