Healthcare Provider Details

I. General information

NPI: 1588063572
Provider Name (Legal Business Name): NORTHWESTERN MEDICAL FACULTY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E. ERIE STREET SUITE#02-220
CHICAGO IL
60611-2661
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE#1000
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8150
  • Fax:
Mailing address:
  • Phone: 312-695-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN A. JOHNSON
Title or Position: VP, CFO
Credential:
Phone: 312-926-1599