Provider Demographics
NPI:1972687317
Name:CONDELL MEDICAL CENTER HOSPICE
Entity Type:Organization
Organization Name:CONDELL MEDICAL CENTER HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRITIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN,MPH
Authorized Official - Phone:847-816-7717
Mailing Address - Street 1:115 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2149
Mailing Address - Country:US
Mailing Address - Phone:847-816-8848
Mailing Address - Fax:847-816-9051
Practice Address - Street 1:115 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2149
Practice Address - Country:US
Practice Address - Phone:847-816-8848
Practice Address - Fax:847-816-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2001121251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9561OtherHOSPICE BLUE CROSS PROVID
IL=========004Medicaid
IL=========OtherHOSPICE TAX ID #
IL141572Medicare ID - Type UnspecifiedMEDICARE PROVIDER #