Healthcare Provider Details

I. General information

NPI: 1689935397
Provider Name (Legal Business Name): SOUTH SHORE HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8012 S CRANDON AVE
CHICAGO IL
60617-1124
US

IV. Provider business mailing address

8012 S CRANDON AVE
CHICAGO IL
60617-1124
US

V. Phone/Fax

Practice location:
  • Phone: 773-356-5000
  • Fax: 773-768-8154
Mailing address:
  • Phone: 773-356-5000
  • Fax: 773-768-8154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number2065105
License Number StateIL

VIII. Authorized Official

Name: MR. TIMOTHY ARTHUR CAVENEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 773-356-5312