Provider Demographics
NPI:1073859104
Name:LOYOLA UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:LOYOLA UNIVERSITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-3215
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:OUTPATIENT CENTER ROOM 1620
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:708-216-8059
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:OUTPATIENT CENTER ROOM 1620
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:708-216-8059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140276Medicare Oscar/Certification