Provider Demographics
NPI:1104953280
Name:ADVENTIST MIDWEST HEALTH
Entity type:Organization
Organization Name:ADVENTIST MIDWEST HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-856-6884
Mailing Address - Street 1:5101 WILLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2600
Mailing Address - Country:US
Mailing Address - Phone:708-245-8900
Mailing Address - Fax:
Practice Address - Street 1:5101 WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2600
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1615787OtherBCBS
1615787OtherBCBS