Provider Demographics
NPI:1790829612
Name:JOHN J. MADDEN MHC PAV-2, UNIT 4470
Entity Type:Organization
Organization Name:JOHN J. MADDEN MHC PAV-2, UNIT 4470
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:NIRDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-338-7048
Mailing Address - Street 1:1200 SOUTH FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-7000
Mailing Address - Country:US
Mailing Address - Phone:708-338-7048
Mailing Address - Fax:708-338-7233
Practice Address - Street 1:1200 SOUTH FIRST AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-7000
Practice Address - Country:US
Practice Address - Phone:708-338-7048
Practice Address - Fax:708-338-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL144028Medicare ID - Type Unspecified