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
State | License ID | Taxonomies |
---|---|---|
207L00000X, 207R00000X, 207RP1001X, 207RR0500X, 207V00000X, 2080N0001X, 208100000X, 2083P0011X, 2084P0804X, 208D00000X, 208VP0000X, 367500000X | ||
IL | 036117915 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2083P0011X | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | Group - Multi-Specialty |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
01622034 | Other | BCBS | |
IL | 01622034 | Other | BLUE SHIELD |
IL | 205335 | Medicare UPIN | |
01622034 | Other | BCBS |