MEDICARE: JACKSON PARK HOSPITAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	273R00000X	Psychiatric Hospital Unit	0001115	IL
2	282N00000X	General Acute Care Hospital	0001115	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0026	OTHER	IL	BLUECROSS

General Provider Information

NPI Number	:	1497750699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PARK HOSPITAL FOUNDATION

Provider Business Mailing Address
First Line	:	7531 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3954
Country	:	US
Telephone Number	:	773-947-7500
Fax Number	:	773-947-7339

Provider Business Practice Location Address
First Line	:	7531 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3954
Country	:	US
Telephone Number	:	773-947-7500
Fax Number	:	773-947-7339

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MERRITT J. HASBROUCK
Credential	:
Telephone Number	:	773-947-7500

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	01/28/2020

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Directions to “JACKSON PARK HOSPITAL FOUNDATION ” Practice Location

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