1053367375 NPI number — NORTHSHORE UNIVERSITY HEALTHSYSTEM

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 1053367375 NPI number — NORTHSHORE UNIVERSITY HEALTHSYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSHORE UNIVERSITY HEALTHSYSTEM
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:
1053367375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 CENTRAL ST
Provider Second Line Business Mailing Address:
RM 222
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-570-5230
Provider Business Mailing Address Fax Number:
847-570-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 PFINGSTEN RD
Provider Second Line Business Practice Location Address:
MEDICAL OFFICE BUILDING SOUTH - SUITE 100
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-1324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-657-1785
Provider Business Practice Location Address Fax Number:
847-657-1787
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WELDAY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
847-570-5099

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  0003483 , 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)





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