Basic Information
| Provider Information | |||||||||
| NPI: | 1376961524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWESTERN MEDICAL FACULTY FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWESTERN MEDICAL GROUP/NM PIMARY & SPECVIALTY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | SUITE #1000 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950665 | ||||||||
| FaxNumber: | 3126956594 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266101 | ||||||||
| FaxNumber: | 3129266332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3126957860 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHWESTERN MEDICAL FACULTY FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DIRECTOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.