Healthcare Provider Details

I. General information

NPI: 1053822080
Provider Name (Legal Business Name): NORTHESTERN ILLINOIS UNIVERSITY STUDENT HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 N SAINT LOUIS AVE RM E-051
CHICAGO IL
60625-4625
US

IV. Provider business mailing address

5500 N SAINT LOUIS AVE RM E-051
CHICAGO IL
60625-4625
US

V. Phone/Fax

Practice location:
  • Phone: 773-442-5800
  • Fax: 773-442-5808
Mailing address:
  • Phone: 773-442-5800
  • Fax: 773-442-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON KAY HEIMBAUGH
Title or Position: DIRECTOR OF STUDENT HEALTH SERVICES
Credential: RN, APN, FNP
Phone: 773-442-5800