Provider Demographics
NPI:1710038633
Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:VISTA MEDICAL CENTER WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PATIENT FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:P
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3672
Mailing Address - Street 1:2615 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4980
Mailing Address - Country:US
Mailing Address - Phone:847-360-4225
Mailing Address - Fax:
Practice Address - Street 1:2615 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4980
Practice Address - Country:US
Practice Address - Phone:847-360-4225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14T033Medicare Oscar/Certification