Basic Information
Provider Information | |||||||||
NPI: | 1962049551 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SWEDISH COVENANT MANAGEMENT SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SWEDISH EMERGENCY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2650 RIDGE AVE STE 1223 | ||||||||
Address2: |   | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602011700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475702040 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5140 N CALIFORNIA AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606253645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475702040 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2019 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADFORD | ||||||||
AuthorizedOfficialFirstName: | CARRIE | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | AVP, PHYSICIAN SERVICES AND CVO | ||||||||
AuthorizedOfficialTelephone: | 8475702041 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SWEDISH COVENANT MANAGEMENT SERVICES, INC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MHA, RHIA, CPMSM, CP | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Emergency | 363A00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207P00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.