Provider Demographics
NPI:1801832548
Name:EVANSTON HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:EVANSTON HOSPITAL CORPORATION
Other - Org Name:EVANSTON REGIONAL HOSP - ER DEPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:PO BOX 60000
Mailing Address - Street 2:FILE 0074044
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160-0001
Mailing Address - Country:US
Mailing Address - Phone:800-819-2547
Mailing Address - Fax:423-899-5295
Practice Address - Street 1:190 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9266
Practice Address - Country:US
Practice Address - Phone:307-783-8161
Practice Address - Fax:307-783-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW308257Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER