=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457604662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWESTERN MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2012
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 E SUPERIOR ST FL 15
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-472-3664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 E HURON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALS INVESTIGATOR
-----------------------------------------------------
Name | DEBORAH LARKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-926-8955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 282N00000X
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------