Provider Demographics
NPI:1407024078
Name:NORTHWESTERN MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:NORTHWESTERN MEMORIAL HOSPITAL
Other - Org Name:NORTHESTERN MEMORIAL HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE VP OF ADMINISTRATION/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-296-2411
Mailing Address - Street 1:251 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-926-2000
Mailing Address - Fax:
Practice Address - Street 1:446 ONTARIO STREET 6TH FL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========009Medicaid
IL=========009Medicaid