Provider Demographics
NPI:1255483962
Name:LOYOLA UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:LOYOLA UNIVERSITY MEDICAL CENTER
Other - Org Name:LOYOLA UNIVERSITY HOME INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MORDACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-4252
Mailing Address - Street 1:9608 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-2238
Mailing Address - Country:US
Mailing Address - Phone:708-216-3510
Mailing Address - Fax:
Practice Address - Street 1:9608 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-2238
Practice Address - Country:US
Practice Address - Phone:708-216-3510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004630251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1671580OtherBLUE CROSS FEDERA
IL0500OtherBLUE CROSS
IL9729OtherBLUE CROSS INFUSION
IL=========401Medicaid
IL=========004Medicaid
IL=========011Medicaid
IL0500OtherBLUE CROSS
IL=========002Medicaid
IL=========005Medicaid
IL=========003Medicaid
IL=========005Medicaid
IL0500OtherBLUE CROSS
IL=========001Medicaid
IL=========004Medicaid
IL0564080001Medicare NSC