1063890184 NPI number — MCDERMOTT CENTER

Table of content: (NPI 1063890184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063890184 NPI number — MCDERMOTT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCDERMOTT CENTER
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:
HAYMARKET CENTER
Provider Other Organization Name Type Code:
3
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:
1063890184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
932 W WASHINGTON BLVD
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:
60607-2217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-226-7984
Provider Business Mailing Address Fax Number:
312-226-8048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 N SANGAMON ST
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60607-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-226-7984
Provider Business Practice Location Address Fax Number:
312-226-8048
Provider Enumeration Date:
05/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LUSTIG
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
312-226-7984

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  A-0349-0032-A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0349-0032 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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