Provider Demographics
NPI:1609956903
Name:RUSH PRESBYTERIAN-ST LUKES MED CTR
Entity Type:Organization
Organization Name:RUSH PRESBYTERIAN-ST LUKES MED CTR
Other - Org Name:RUSH CRANIOFACIAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:POLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-563-3000
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 425, POB 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-563-3000
Mailing Address - Fax:312-563-2514
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 425, POB 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-563-3000
Practice Address - Fax:312-563-2514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019018936Medicaid
IL21623004OtherJWP-RCFC #
IL036079739Medicaid
IL32517OtherAAF-RCFC #
IL918610Medicare ID - Type UnspecifiedJWP-RCFC #
ILE68962Medicare UPIN
IL32517OtherAAF-RCFC #
IL019018936Medicaid