Provider Demographics
NPI:1043213911
Name:CONDELL MEDICAL CENTER
Entity Type:Organization
Organization Name:CONDELL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-990-5202
Mailing Address - Street 1:900 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3141
Mailing Address - Country:US
Mailing Address - Phone:847-362-2900
Mailing Address - Fax:847-573-4304
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3199
Practice Address - Country:US
Practice Address - Phone:847-362-2900
Practice Address - Fax:847-573-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000422282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0008Medicaid
IL=========401Medicaid
IL=========001Medicaid
IL=========007Medicaid
IL201777Medicare PIN
IL140202Medicare Oscar/Certification
IL=========0008Medicaid