Basic Information
| Provider Information | |||||||||
| NPI: | 1821048786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF CHICAGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HARVESTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737026400 | ||||||||
| FaxNumber: | 7737020000 | ||||||||
| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE | ||||||||
| Address2: | UCPG/MC 1099 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737029200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | OSTRANDER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER - PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 7738344508 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.