Provider Demographics
NPI:1093097040
Name:NORTHWESTERN MEMORIAL PHYSICIANS GROUP
Entity Type:Organization
Organization Name:NORTHWESTERN MEMORIAL PHYSICIANS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-926-6147
Mailing Address - Street 1:1460 N HALSTED ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 N HALSTED ST
Practice Address - Street 2:SUITE 502
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2605
Practice Address - Country:US
Practice Address - Phone:312-926-7028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095919332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site