Provider Demographics
NPI:1902854623
Name:CGH MEDICAL CENTER
Entity Type:Organization
Organization Name:CGH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR PATIENT ACCOUNTS
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-625-0400
Mailing Address - Street 1:100 E LE FEVRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1278
Mailing Address - Country:US
Mailing Address - Phone:815-625-0400
Mailing Address - Fax:815-625-2747
Practice Address - Street 1:100 E LE FEVRE RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1278
Practice Address - Country:US
Practice Address - Phone:815-625-0400
Practice Address - Fax:815-625-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
273R00000X
IL0000364275N00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0101OtherJOHN DEERE
ILCE7487OtherRAILROAD MEDICARE
L011619OtherTRICARE
ILIL0101OtherJOHN DEERE
L011619OtherTRICARE
IL140043Medicare ID - Type Unspecified
IL14U043Medicare ID - Type UnspecifiedCGH SWING BEDS
IL625210Medicare PIN
IL210704Medicare PIN
IL=========401Medicaid