Provider Demographics
NPI:1073794517
Name:ST JAMES HOSPITAL UNITED STATES CATHOLIC CONFERENCE
Entity Type:Organization
Organization Name:ST JAMES HOSPITAL UNITED STATES CATHOLIC CONFERENCE
Other - Org Name:ST JAMES DIABETES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-755-3348
Mailing Address - Street 1:30 E 15TH ST
Mailing Address - Street 2:SUITE 314
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3459
Mailing Address - Country:US
Mailing Address - Phone:708-709-2010
Mailing Address - Fax:708-755-3393
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:SUITE 314
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:708-709-2010
Practice Address - Fax:708-755-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1813312261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC1471OtherRAILROAD
IL036046124Medicaid
IL1619159OtherBLUE CROSS BLUE SHIELD
IL806290Medicare PIN
ILCC1471OtherRAILROAD