Basic Information
| Provider Information | |||||||||
| NPI: | 1528488897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOYOLA UNIVERSITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | LOYOLA OUTPATIENT CENTER, 4300 | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166006 | ||||||||
| FaxNumber: | 7082162683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | VANDLIK | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERNAL MEDICINE RESIDENCY PROGRAM | ||||||||
| AuthorizedOfficialTelephone: | 7082166497 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOYOLA UNIVERSITY CHICAGO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.