Provider Demographics
NPI:1629147210
Name:ST BERNARD HOSPITAL
Entity Type:Organization
Organization Name:ST BERNARD HOSPITAL
Other - Org Name:ST. BERNARD ANESTHESIA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN STRATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-962-4100
Mailing Address - Street 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:ST. BERNARD HOSPITAL - ANESTHESIA DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-962-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL800950Medicare PIN
IL210329Medicare PIN