Provider Demographics
NPI:1497825855
Name:SWEDISH COVENANT HEALTH
Entity Type:Organization
Organization Name:SWEDISH COVENANT HEALTH
Other - Org Name:FOSTER MEDICAL PAVILION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST VP ACCOUNTING AND TAX
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-570-5103
Mailing Address - Street 1:5215 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE F103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3513
Mailing Address - Country:US
Mailing Address - Phone:773-989-6280
Mailing Address - Fax:773-989-6285
Practice Address - Street 1:5215 N CALIFORNIA AVE
Practice Address - Street 2:SUITE F103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3513
Practice Address - Country:US
Practice Address - Phone:773-989-6280
Practice Address - Fax:773-989-6285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SWEDISH COVENANT HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540153593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364073303003Medicaid
IL5505400003Medicare PIN