Provider Demographics
NPI:1609813419
Name:CONDELL MEDICAL CENTER
Entity Type:Organization
Organization Name:CONDELL MEDICAL CENTER
Other - Org Name:CONDELL MED CTR GRAYS LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-990-5205
Mailing Address - Street 1:900 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3141
Mailing Address - Country:US
Mailing Address - Phone:847-362-2905
Mailing Address - Fax:
Practice Address - Street 1:1170 E BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2061
Practice Address - Country:US
Practice Address - Phone:847-223-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000422261QR0207X
IL282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid