Provider Demographics
NPI:1215141627
Name:PRESENCE HOSPITALS PRV
Entity type:Organization
Organization Name:PRESENCE HOSPITALS PRV
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SYSTEM, CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-7674
Mailing Address - Street 1:500 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3661
Mailing Address - Country:US
Mailing Address - Phone:815-937-2490
Mailing Address - Fax:
Practice Address - Street 1:100 PROVENA WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4796
Practice Address - Country:US
Practice Address - Phone:815-937-8780
Practice Address - Fax:815-937-8241
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESENCE HOSPITALS - PRV
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004879207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004621885OtherBLUE CROSS BLUE SHIELD