Provider Demographics
NPI:1356313506
Name:EVANSTON HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:EVANSTON HOSPITAL CORPORATION
Other - Org Name:EVANSTON REGIONAL HOSPITAL
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:PO BOX 6000 FILE 73783
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 ARROWHEAD DR
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:307-783-8167
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANSTON HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-02
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-165275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
41376OtherBCBS
WY114835406Medicaid
41376OtherBCBS