Provider Demographics
NPI:1306029889
Name:ROSELAND COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:ROSELAND COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:ROSELAND COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:773-995-3000
Mailing Address - Street 1:45 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4294
Mailing Address - Country:US
Mailing Address - Phone:773-995-3116
Mailing Address - Fax:773-660-4505
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-3000
Practice Address - Fax:773-995-6602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSELAND COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207R00000X, 207RP1001X, 207RR0500X, 207V00000X, 2080N0001X, 208100000X, 2083P0011X, 2084P0804X, 208D00000X, 208VP0000X, 367500000X
IL036117915208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01622034OtherBCBS
IL01622034OtherBLUE SHIELD
IL205335Medicare UPIN
01622034OtherBCBS