Provider Demographics
NPI:1164703823
Name:SAINT ANTHONY PHO, LLC
Entity Type:Organization
Organization Name:SAINT ANTHONY PHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE COMMITTEE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-484-4015
Mailing Address - Street 1:2875 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3501
Mailing Address - Country:US
Mailing Address - Phone:773-484-4015
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization