Provider Demographics
NPI:1588010276
Name:COLLEGE OF NURSING FACULTY PRACTICE
Entity Type:Organization
Organization Name:COLLEGE OF NURSING FACULTY PRACTICE
Other - Org Name:RUSH ADOLESCENT FAMILY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLENWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-942-2859
Mailing Address - Street 1:1645 W JACKSON BLVD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3276
Mailing Address - Country:US
Mailing Address - Phone:312-942-2777
Mailing Address - Fax:312-942-2822
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:SUITE 315
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:312-942-2777
Practice Address - Fax:312-942-2822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility