Provider Demographics
NPI:1073525754
Name:GLEN MORTON MEDICAL CENTER, S.C.
Entity Type:Organization
Organization Name:GLEN MORTON MEDICAL CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, OCN
Authorized Official - Phone:847-965-3200
Mailing Address - Street 1:9129 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2120
Mailing Address - Country:US
Mailing Address - Phone:847-965-3200
Mailing Address - Fax:847-965-3301
Practice Address - Street 1:9129 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2120
Practice Address - Country:US
Practice Address - Phone:847-965-3200
Practice Address - Fax:847-965-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006744207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042-006744OtherMEDICAL CORP.LICENSE
IL966420OtherMEDICARE GROUP
IL042-006744OtherMEDICAL CORP.LICENSE