Provider Demographics
NPI:1518915248
Name:RUSH UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:RUSH UNIVERSITY MEDICAL CENTER
Other - Org Name:RUSH UNIVERSITY PRIMARY CARE - LINCOLN PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-942-6909
Mailing Address - Street 1:2835 N SHEFFIELD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5081
Mailing Address - Country:US
Mailing Address - Phone:773-472-3704
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5081
Practice Address - Country:US
Practice Address - Phone:773-472-3704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-05
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623497OtherBC PPO
IL01623497OtherBC PPO