Provider Demographics
NPI:1235148891
Name:LOYOLA UNIVERSITY PHYSICIAN FOUNDATION
Entity Type:Organization
Organization Name:LOYOLA UNIVERSITY PHYSICIAN FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-3981
Mailing Address - Street 1:2 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:S#600
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5702
Mailing Address - Country:US
Mailing Address - Phone:800-424-6307
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:800-424-6307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL592400Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL366800Medicare PIN
IL366800Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL592380Medicare PIN
IL592400Medicare PIN
IL205471Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL205471Medicare PIN