Basic Information
Provider Information | |||||||||
NPI: | 1831516210 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOYOLA UNIVERSITY CHICAGO MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2160 S 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | MAYWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 601533328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2160 S 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | MAYWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 601533328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885847888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2014 | ||||||||
LastUpdateDate: | 03/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STROWD | ||||||||
AuthorizedOfficialFirstName: | SARA | ||||||||
AuthorizedOfficialMiddleName: | MILLER | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL STUDENT | ||||||||
AuthorizedOfficialTelephone: | 8885847888 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 390200000 | IL | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.