Healthcare Provider Details

I. General information

NPI: 1912283268
Provider Name (Legal Business Name): NORTHWESTERN MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 630-935-0128
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number209009062
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209009062
License Number StateIL

VIII. Authorized Official

Name: LAUREN MANZARA
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 630-935-0128