Provider Demographics
NPI:1487864419
Name:BLUE ISLAND NURSING HOME
Entity Type:Organization
Organization Name:BLUE ISLAND NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ZOHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HOCHENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:312-330-5759
Mailing Address - Street 1:2427 BURR OAK AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2024
Mailing Address - Country:US
Mailing Address - Phone:708-389-7799
Mailing Address - Fax:708-389-8799
Practice Address - Street 1:2427 BURR OAK AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2024
Practice Address - Country:US
Practice Address - Phone:708-389-7799
Practice Address - Fax:708-389-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0035394313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid