Provider Demographics
NPI:1366526709
Name:CONDELL MEDICAL CENTER HOME MEDICAL EQUIPMENT
Entity type:Organization
Organization Name:CONDELL MEDICAL CENTER HOME MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRITIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN,MPH
Authorized Official - Phone:847-816-7717
Mailing Address - Street 1:115 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2149
Mailing Address - Country:US
Mailing Address - Phone:847-816-7717
Mailing Address - Fax:847-367-9078
Practice Address - Street 1:28835 N HERKY DR
Practice Address - Street 2:UNIT 201
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1464
Practice Address - Country:US
Practice Address - Phone:847-367-5750
Practice Address - Fax:847-362-2780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04921644OtherHME BLUE CROSS #
IL=========OtherTAX ID #
IL04921644OtherHME BLUE CROSS #
IL=========005Medicaid