Basic Information
| Provider Information | |||||||||
| NPI: | 1225479470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH SHORE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8012 S CRANDON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606171124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733565200 | ||||||||
| FaxNumber: | 7737688154 | ||||||||
| Practice Location | |||||||||
| Address1: | 8012 S CRANDON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606171124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733565200 | ||||||||
| FaxNumber: | 7737688154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2013 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7733565200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164.004009 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 163W00000X | 041.147476 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 51204952001 | 05 | IL | MEDICAID | 214641 | 01 | IL | AMERICAN ASSOCIATION OF DIABETES EDUCATORS | OTHER |