Provider Demographics
NPI:1225141104
Name:GOTTLIEB MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GOTTLIEB MEMORIAL HOSPITAL
Other - Org Name:GOTTLIEB HOSPICE PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-4252
Mailing Address - Street 1:701 WEST NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1602
Mailing Address - Country:US
Mailing Address - Phone:708-681-3200
Mailing Address - Fax:708-450-5058
Practice Address - Street 1:701 WEST NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1602
Practice Address - Country:US
Practice Address - Phone:708-216-4983
Practice Address - Fax:708-216-0808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOTTLIEB MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005561251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9559OtherBLUE CROSS
IL141561Medicare Oscar/Certification
IL=========005Medicaid
IL=========401Medicaid