Healthcare Provider Details

I. General information

NPI: 1396250304
Provider Name (Legal Business Name): JACKSON PARK HOSPITAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 773-947-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0001115
License Number StateIL

VIII. Authorized Official

Name: MR. BARRY R MANDELL
Title or Position: VP OF SPECIAL PROJECTS
Credential:
Phone: 773-947-7701