Healthcare Provider Details

I. General information

NPI: 1609956903
Provider Name (Legal Business Name): RUSH PRESBYTERIAN-ST LUKES MED CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 425, POB 1
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 425, POB 1
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-3000
  • Fax: 312-563-2514
Mailing address:
  • Phone: 312-563-3000
  • Fax: 312-563-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN W. POLLEY
Title or Position: MANAGER
Credential:
Phone: 312-563-3000