Provider Demographics
NPI:1154503597
Name:PHWD, LLC
Entity Type:Organization
Organization Name:PHWD, LLC
Other - Org Name:ALL FAITH PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-4100
Mailing Address - Street 1:7444 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3214
Mailing Address - Country:US
Mailing Address - Phone:847-329-4100
Mailing Address - Fax:847-329-4900
Practice Address - Street 1:3500 S GILES AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1106
Practice Address - Country:US
Practice Address - Phone:312-326-2000
Practice Address - Fax:312-326-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0020404314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
14-5856OtherMEDICARE PROVIDER A
14-5856OtherMEDICARE PROVIDER A