Provider Demographics
NPI:1790898674
Name:GOTTLIEB MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GOTTLIEB MEMORIAL HOSPITAL
Other - Org Name:GOTTLIEB MEMORIAL DIETICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-681-3200
Mailing Address - Street 1:701 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1612
Mailing Address - Country:US
Mailing Address - Phone:708-681-3200
Mailing Address - Fax:708-450-5058
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-681-3200
Practice Address - Fax:708-450-5058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOTTLIEB MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1630768133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201896Medicare PIN