1013014042 NPI number — GYNECOLOGIC SPECIALISTS OF NORTHWESTERN, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013014042 NPI number — GYNECOLOGIC SPECIALISTS OF NORTHWESTERN, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GYNECOLOGIC SPECIALISTS OF NORTHWESTERN, S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013014042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E DELAWARE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-1814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-654-5292
Provider Business Mailing Address Fax Number:
312-654-5588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 N LAKE SHORE DR
Provider Second Line Business Practice Location Address:
SUITE117
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-4546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-654-1166
Provider Business Practice Location Address Fax Number:
312-654-5288
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLUMENTHAL
Authorized Official First Name:
JANE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/TREASURER
Authorized Official Telephone Number:
312-654-1166

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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