Provider Demographics
NPI:1124005517
Name:GOTTLIEB MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GOTTLIEB MEMORIAL HOSPITAL
Other - Org Name:GOTTLIEB PROFESSIONAL BUILDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR BILLING OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ADENRELE
Authorized Official - Middle Name:ADEKUNBI
Authorized Official - Last Name:KOLAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-3743
Mailing Address - Street 1:701 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1612
Mailing Address - Country:US
Mailing Address - Phone:708-450-4941
Mailing Address - Fax:708-681-4673
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-4941
Practice Address - Fax:708-681-4673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOTTLIEB MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-27
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054008713333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy