=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235471228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWESTERN MEDICAL FACULTY FOUDNATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2013
-----------------------------------------------------
Last Update Date | 03/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 E SUPERIOR ST LURIE 10-109
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-503-1531
-----------------------------------------------------
Fax | 312-503-6262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 E SUPERIOR ST LURIE 10-109
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-503-1531
-----------------------------------------------------
Fax | 312-503-6262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF, DIVISION ONF NEPHROLOGY
-----------------------------------------------------
Name | SUSAN E QUAGGIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 312-503-1531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 036131841
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------