Basic Information
| Provider Information | |||||||||
| NPI: | 1518324961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWESTERN MEDICAL FACULTY FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWESTERN MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1475 E BELVIDERE RD | ||||||||
| Address2: | PAVILION C,SUITE# 385 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600302012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126941469 | ||||||||
| FaxNumber: | 3126940655 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | SUITE# 1000 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126959797 | ||||||||
| FaxNumber: | 3126950050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3126957860 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.