Provider Demographics
NPI:1376788810
Name:STATE HOSPITAL OF ILLINOIS
Entity Type:Organization
Organization Name:STATE HOSPITAL OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOC
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-227-4098
Mailing Address - Street 1:8461 WALREDON AVE
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6351
Mailing Address - Country:US
Mailing Address - Phone:630-227-4098
Mailing Address - Fax:
Practice Address - Street 1:8461 WALREDON AVE
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6351
Practice Address - Country:US
Practice Address - Phone:630-227-4098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILILHOS1282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital