Provider Demographics
NPI:1518324961
Name:NORTHWESTERN MEDICAL FACULTY FOUNDATION
Entity Type:Organization
Organization Name:NORTHWESTERN MEDICAL FACULTY FOUNDATION
Other - Org Name:NORTHWESTERN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:312-695-7860
Mailing Address - Street 1:1475 E BELVIDERE RD
Mailing Address - Street 2:PAVILION C,SUITE# 385
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:312-694-1469
Mailing Address - Fax:312-694-0655
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE# 1000
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-695-9797
Practice Address - Fax:312-695-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4720Medicare PIN