Basic Information
| Provider Information | |||||||||
| NPI: | 1134162894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIT LINCOLN PARK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 OTIS BOWEN DR | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199345300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 W WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199345300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | CURRAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7738833800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036066878 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1635013 | 01 | IL | IL BCBS | OTHER |