Provider Demographics
NPI:1538215611
Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Entity type:Organization
Organization Name:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT GROUP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:60 S GREENLEAF ST
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3300
Mailing Address - Country:US
Mailing Address - Phone:847-360-4225
Mailing Address - Fax:
Practice Address - Street 1:60 S GREENLEAF ST
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3300
Practice Address - Country:US
Practice Address - Phone:847-360-4225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUKEGAN ILLINOIS HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213896Medicare ID - Type UnspecifiedPART B