MEDICARE: CHICAGO WOMEN'S HEALTH GROUP AT NORTHWESTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	042006984	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016-20273	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1053377473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO WOMEN'S HEALTH GROUP AT NORTHWESTERN

Provider Business Mailing Address
First Line	:	333 E SUPERIOR ST
Second Line	:	SUITE 444
City	:	CHICAGO
State	:	IL
Zip	:	60611-2654
Country	:	US
Telephone Number	:	312-943-0282
Fax Number	:	312-943-0284

Provider Business Practice Location Address
First Line	:	333 E SUPERIOR ST
Second Line	:	SUITE 444
City	:	CHICAGO
State	:	IL
Zip	:	60611-2654
Country	:	US
Telephone Number	:	312-943-0282
Fax Number	:	312-943-0284

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MARY MOORE
Credential	:
Telephone Number	:	312-943-0282

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	08/22/2020

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