Healthcare Provider Details

I. General information

NPI: 1336159961
Provider Name (Legal Business Name): LOYOLA UNIVERSITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-3215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SHAWN VINCENT
Title or Position: PRESIDENT & CEO
Credential:
Phone: 708-216-3215