Provider Demographics
NPI:1942084538
Name:MERCY CRYSTAL LAKE HOSPITAL AND MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MERCY CRYSTAL LAKE HOSPITAL AND MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-971-6752
Mailing Address - Street 1:875 S. ROUTE 31
Mailing Address - Street 2:STE 1-100L
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8190
Mailing Address - Country:US
Mailing Address - Phone:779-220-5200
Mailing Address - Fax:779-220-5325
Practice Address - Street 1:875 S. ROUTE 31
Practice Address - Street 2:STE 1-100L
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8190
Practice Address - Country:US
Practice Address - Phone:779-220-5200
Practice Address - Fax:779-220-5325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-022562OtherIL STATE LICENSE