Basic Information
| Provider Information | |||||||||
| NPI: | 1023067154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCH SURGICAL AFFILIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 W HARRISON ST | ||||||||
| Address2: | SUITE 818 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129426511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1725 W HARRISON ST | ||||||||
| Address2: | SUITE 818 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129426511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3129426909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01623879 | 01 | IL | BC PPO | OTHER |