Healthcare Provider Details

I. General information

NPI: 1538111299
Provider Name (Legal Business Name): NORTHWESTERN MEMORIAL PHYSICIANS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR SUITE 818
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 818
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6146
  • Fax:
Mailing address:
  • Phone: 312-926-6146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036-061908
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036070574
License Number StateIL

VIII. Authorized Official

Name: JUSTIN JOHNSON
Title or Position: VP FINANCE
Credential:
Phone: 312-926-1599