Provider Demographics
NPI:1447298450
Name:NORTHERN ILLINOIS MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHERN ILLINOIS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CIO & CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-788-5831
Mailing Address - Street 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-344-6602
Mailing Address - Fax:
Practice Address - Street 1:213 FRONT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5501
Practice Address - Country:US
Practice Address - Phone:815-344-6602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN ILLINOIS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1003201251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9840OtherBLUE CROSS BLUE SHEILD
ID=========OtherOTHER INSURANCE PROVIDERS
IL=========004Medicaid
IL=========004Medicaid