Provider Demographics
NPI:1124272547
Name:ADVOCATE CONDELL MEDICAL CENTER
Entity type:Organization
Organization Name:ADVOCATE CONDELL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP MANAGED HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0450
Mailing Address - Street 1:900 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3141
Mailing Address - Country:US
Mailing Address - Phone:847-362-2900
Mailing Address - Fax:847-573-4304
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-362-2900
Practice Address - Fax:847-573-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
IL0000422282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140202Medicare Oscar/Certification