Provider Demographics
NPI:1518202225
Name:BETHANY HOMES AND METHODIST HOSPITAL
Entity Type:Organization
Organization Name:BETHANY HOMES AND METHODIST HOSPITAL
Other - Org Name:EGEL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-653-5630
Mailing Address - Street 1:5113 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2807
Mailing Address - Country:US
Mailing Address - Phone:773-293-4090
Mailing Address - Fax:773-293-4503
Practice Address - Street 1:5113 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2807
Practice Address - Country:US
Practice Address - Phone:773-293-4090
Practice Address - Fax:773-293-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty