Basic Information
Provider Information
NPI: 1871560961
EntityType: 2
ReplacementNPI:  
OrganizationName: RUSH UNIVERSITY MEDICAL CENTER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: RUSH PEDIATRIC MEDICAL SERVICE PLAN
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1725 W HARRISON ST
Address2: SUITE 710
City: CHICAGO
State: IL
PostalCode: 606123841
CountryCode: US
TelephoneNumber: 3129423034
FaxNumber:  
Practice Location
Address1: 1725 W HARRISON ST
Address2: SUITE 710
City: CHICAGO
State: IL
PostalCode: 606123841
CountryCode: US
TelephoneNumber: 3129423034
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/07/2006
LastUpdateDate: 07/12/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BOYER
AuthorizedOfficialFirstName: KENNETH
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: AUTHORIZED OFFICIAL
AuthorizedOfficialTelephone: 3129422200
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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