Basic Information
| Provider Information | |||||||||
| NPI: | 1689935397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE HOSPITAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8012 S CRANDON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606171124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733565000 | ||||||||
| FaxNumber: | 7737688154 | ||||||||
| Practice Location | |||||||||
| Address1: | 8012 S CRANDON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606171124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733565000 | ||||||||
| FaxNumber: | 7737688154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAVENEY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7733565312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 2065105 | IL | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 510204952001 | 05 | IL | MEDICAID | 510204952401 | 05 | IL | MEDICAID |