Provider Demographics
NPI:1619143997
Name:GLENBROOK HOSPITAL
Entity Type:Organization
Organization Name:GLENBROOK HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WEST
Authorized Official - Suffix:III
Authorized Official - Credentials:PA
Authorized Official - Phone:847-657-5815
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:ROOM 1223
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1644
Mailing Address - Fax:847-733-5315
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:ROOM 1223
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-1644
Practice Address - Fax:847-733-5315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANSTON NORTHWESTERN HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000949282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital