Provider Demographics
NPI:1255304051
Name:EVANSTON HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:EVANSTON HOSPITAL CORPORATION
Other - Org Name:EVANSTON DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE OPERATIONS/AO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3840
Mailing Address - Street 1:190 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9266
Mailing Address - Country:US
Mailing Address - Phone:307-789-3636
Mailing Address - Fax:
Practice Address - Street 1:112 YELLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9266
Practice Address - Country:US
Practice Address - Phone:307-789-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANSTON HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-10
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-102261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114835407Medicaid
WY114835407Medicaid