Provider Demographics
NPI:1083929640
Name:SAINT MARY AND ELIZABETH HOSPITAL
Entity Type:Organization
Organization Name:SAINT MARY AND ELIZABETH HOSPITAL
Other - Org Name:RHS
Other - Org Type:Other Name
Authorized Official - Title/Position:FAMILY MEDICINE RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMUDIO RASOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-226-0821
Mailing Address - Street 1:1404 HACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4021
Mailing Address - Country:US
Mailing Address - Phone:847-236-0045
Mailing Address - Fax:847-236-0045
Practice Address - Street 1:1127 N OAKLEY BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3507
Practice Address - Country:US
Practice Address - Phone:312-770-2040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-07
Last Update Date:2010-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058811282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125058811OtherILLINOIS TEMPORARY PHYSICIAN LICENSE