Provider Demographics
NPI:1558573733
Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM FACULTY PRACTICE ASSOCIATES
Entity Type:Organization
Organization Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM FACULTY PRACTICE ASSOCIATES
Other - Org Name:NORTHSHORE PATHOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR, FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WASHA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:847-570-5230
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:RM 1922B
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2000
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:RM 1922B
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205621Medicare PIN
IL205628Medicare PIN