Healthcare Provider Details

I. General information

NPI: 1770992448
Provider Name (Legal Business Name): NORTHWESTERN MEDICAL FACULTY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 E BELVIDERE RD SUITE# 1297
GRAYSLAKE IL
60030-2012
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE# 1000
CHICAGO IL
60611-8709
US

V. Phone/Fax

Practice location:
  • Phone: 847-295-0001
  • Fax:
Mailing address:
  • Phone: 312-695-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN A. JOHNSON
Title or Position: VP,CFO
Credential: 01041973
Phone: 312-926-1599