Provider Demographics
NPI:1184661514
Name:CGH MEDICAL CENTER
Entity Type:Organization
Organization Name:CGH MEDICAL CENTER
Other - Org Name:CGH HOME INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENTGES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:815-622-0836
Mailing Address - Street 1:3010 E. LYNN BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081
Mailing Address - Country:US
Mailing Address - Phone:815-625-3476
Mailing Address - Fax:
Practice Address - Street 1:3010 E. LYNN BLVD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081
Practice Address - Country:US
Practice Address - Phone:815-622-0836
Practice Address - Fax:815-622-9456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CGH MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL093013381251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09823789OtherBLUE CROSS
IL09823789OtherBLUE CROSS
IL1193920001Medicare NSC