Provider Demographics
NPI:1952429045
Name:ST. JAMES PHYSICIAN HOSPITAL ORGANIZATION
Entity Type:Organization
Organization Name:ST. JAMES PHYSICIAN HOSPITAL ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-709-2011
Mailing Address - Street 1:30 E 15TH ST
Mailing Address - Street 2:SUITE #402
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3459
Mailing Address - Country:US
Mailing Address - Phone:708-709-2011
Mailing Address - Fax:708-709-2002
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:SUITE #402
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:708-709-2011
Practice Address - Fax:708-709-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization