Provider Demographics
NPI:1700864352
Name:GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION
Entity Type:Organization
Organization Name:GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BILLING AND COLLECTIONS
Authorized Official - Prefix:
Authorized Official - First Name:ADENRELE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-3743
Mailing Address - Street 1:3249 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:615-665-6000
Mailing Address - Fax:615-665-6184
Practice Address - Street 1:3249 SOUTH OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-783-3222
Practice Address - Fax:708-783-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005082273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14S054Medicare Oscar/Certification