Basic Information
| Provider Information | |||||||||
| NPI: | 1194939215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOSEPH HOSPITAL | ||||||||
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| OtherOrganizationName: | SJH PEDIATRIC OPTHALMOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 TRANSAM PLAZA DR. | ||||||||
| Address2: | SUITE 490 | ||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304241122 | ||||||||
| FaxNumber: | 6304241678 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR. | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | STRUXNESS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7736653000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 036074319 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01632129 | 01 | IL | BCBS OF IL GROUP PROVIDER | OTHER |