Provider Demographics
NPI:1568472819
Name:ROSELAND COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:ROSELAND COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:ROSELAND COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-995-3000
Mailing Address - Street 1:45 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4200
Mailing Address - Country:US
Mailing Address - Phone:773-995-3000
Mailing Address - Fax:773-995-6602
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-3000
Practice Address - Fax:773-995-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084A0401X
IL0002063273R00000X, 282N00000X, 283Q00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No273R00000XHospital UnitsPsychiatric Unit
No283Q00000XHospitalsPsychiatric Hospital
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========401Medicaid
IL=========001Medicaid
IL=========401Medicaid
IL805740Medicare PIN