Provider Demographics
NPI:1801812284
Name:ST. PAULS CORPORATION
Entity type:Organization
Organization Name:ST. PAULS CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:PAULSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-368-7300
Mailing Address - Street 1:3800 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3606
Mailing Address - Country:US
Mailing Address - Phone:773-478-4222
Mailing Address - Fax:773-478-4516
Practice Address - Street 1:3800 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3606
Practice Address - Country:US
Practice Address - Phone:773-478-4222
Practice Address - Fax:773-478-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005165314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid
IL0736930001Medicare NSC