Provider Demographics
NPI:1750752739
Name:CGH MEDICAL CENTER
Entity type:Organization
Organization Name:CGH MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-564-4633
Mailing Address - Street 1:100 E LEFEVRE 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:815-564-4633
Mailing Address - Fax:815-632-5949
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:815-564-4633
Practice Address - Fax:815-632-5949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540173883336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155581OtherPK
IL=========001Medicaid