Provider Demographics
NPI:1598175507
Name:LOYOLA UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:LOYOLA UNIVERSITY MEDICAL CENTER
Other - Org Name:LOYOLA UNIVERSITY MEDICAL CTR OPTICAL SHOP AT BURR RIDGE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-216-4252
Mailing Address - Street 1:2160 S. FIRST AVENUE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3304
Mailing Address - Country:US
Mailing Address - Phone:708-216-8686
Mailing Address - Fax:708-216-8059
Practice Address - Street 1:6800 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7819
Practice Address - Country:US
Practice Address - Phone:708-327-1004
Practice Address - Fax:708-327-1003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOYOLA UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-29
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140276Medicare UPIN
140008Medicare UPIN