Provider Demographics
NPI:1447418017
Name:HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:HEALTH DEPARTMENT
Other - Org Name:ST BERNARD HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRATHIBHA
Authorized Official - Middle Name:V
Authorized Official - Last Name:THARIMALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-667-4631
Mailing Address - Street 1:5400 S HYDE PARK BLVD APT D2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5852
Mailing Address - Country:US
Mailing Address - Phone:773-667-4631
Mailing Address - Fax:
Practice Address - Street 1:5400 S HYDE PARK BLVD APT D2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5852
Practice Address - Country:US
Practice Address - Phone:773-667-4631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048048261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU45703Medicaid