Basic Information
| Provider Information | |||||||||
| NPI: | 1255715488 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWESTERN MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N FAIRBANKS CT # 7121 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 710 N FAIRBANKS CT # 7121 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERANEK | ||||||||
| AuthorizedOfficialFirstName: | CAITLIN | ||||||||
| AuthorizedOfficialMiddleName: | ELYSE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIETITIAN | ||||||||
| AuthorizedOfficialTelephone: | 3129267437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RD, LDN, CNSC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.