Provider Demographics
NPI:1407381197
Name:NORTHWESTERN MEMORIAL HEALTHCARE
Entity Type:Organization
Organization Name:NORTHWESTERN MEMORIAL HEALTHCARE
Other - Org Name:NORTHWESTERN MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LATIFAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:312-926-6354
Mailing Address - Street 1:675 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 21-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5975
Mailing Address - Country:US
Mailing Address - Phone:312-695-1192
Mailing Address - Fax:312-695-1106
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 21-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-1192
Practice Address - Fax:312-695-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005630261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology