Healthcare Provider Details

I. General information

NPI: 1063504165
Provider Name (Legal Business Name): LOYOLA UNIVERSITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S FIRST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax: 708-216-0593
Mailing address:
  • Phone: 708-216-3510
  • Fax: 708-216-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472R0900X
TaxonomyRenal Dialysis Technician
License Number0004630
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0005801
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number0005801
License Number StateIL

VIII. Authorized Official

Name: MELISSA M LUKASICK
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 708-216-5723