Provider Demographics
NPI:1164522447
Name:PROVIDENT HOSPITAL OF COOK COUNTY
Entity Type:Organization
Organization Name:PROVIDENT HOSPITAL OF COOK COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS - HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-572-1202
Mailing Address - Street 1:400 VILLAGE CIR
Mailing Address - Street 2:UNIT 110
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1802
Mailing Address - Country:US
Mailing Address - Phone:708-839-1833
Mailing Address - Fax:
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-1202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE 93362Medicare UPIN