Provider Demographics
NPI:1659401909
Name:HINES VA HOSPITAL
Entity Type:Organization
Organization Name:HINES VA HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRT
Authorized Official - Prefix:
Authorized Official - First Name:JACALYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LYLES-CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-202-8387
Mailing Address - Street 1:5923 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:IL
Mailing Address - Zip Code:60163-1545
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5923 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:IL
Practice Address - Zip Code:60163-1545
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital