=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740567312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON PARK HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2011
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 E 75TH ST 1ST FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-947-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 E 75TH ST 1ST FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-947-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | RUKSANA NAZNEEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-947-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 125.060628
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------