Provider Demographics
NPI:1700884731
Name:NORTHERN ILLINOIS HOSPICE ASSOCIATION
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS HOSPICE ASSOCIATION
Other - Org Name:NORTHERN ILLINOIS HOSPICE AND GRIEF CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-398-0500
Mailing Address - Street 1:4751 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-7929
Mailing Address - Country:US
Mailing Address - Phone:815-398-0500
Mailing Address - Fax:815-398-0588
Practice Address - Street 1:4751 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-7929
Practice Address - Country:US
Practice Address - Phone:815-398-0500
Practice Address - Fax:815-398-0588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000313251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9579OtherBLUECROSS/BLUESHIELD PROV
ID9579OtherBLUECROSS/BLUESHIELD PROV
ID9579OtherBLUECROSS/BLUESHIELD PROV