Provider Demographics
NPI:1588842470
Name:ST. MARY OF PROVIDENCE
Entity Type:Organization
Organization Name:ST. MARY OF PROVIDENCE
Other - Org Name:ROSE ANGELA HALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, NHA
Authorized Official - Phone:773-545-8300
Mailing Address - Street 1:4200 N AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1615
Mailing Address - Country:US
Mailing Address - Phone:773-545-8300
Mailing Address - Fax:773-545-2984
Practice Address - Street 1:4200 N AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1615
Practice Address - Country:US
Practice Address - Phone:773-545-8300
Practice Address - Fax:773-545-2984
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY OF PROVIDENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033761315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14G191Medicaid