Provider Demographics
NPI:1225479470
Name:SOUTH SHORE HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH SHORE HOSPITAL CORPORATION
Other - Org Name:SOUTH SHORE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:CHE
Authorized Official - Phone:773-356-5200
Mailing Address - Street 1:8012 S CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1124
Mailing Address - Country:US
Mailing Address - Phone:773-356-5200
Mailing Address - Fax:773-768-8154
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-356-5200
Practice Address - Fax:773-768-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004009133V00000X
IL041.147476163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL51204952001Medicaid
IL214641OtherAMERICAN ASSOCIATION OF DIABETES EDUCATORS
IL214641OtherAMERICAN ASSOCIATION OF DIABETES EDUCATORS