Provider Demographics
NPI:1689935397
Name:SOUTH SHORE HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH SHORE HOSPITAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:CAVENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-356-5312
Mailing Address - Street 1:8012 S CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1124
Mailing Address - Country:US
Mailing Address - Phone:773-356-5000
Mailing Address - Fax:773-768-8154
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-356-5000
Practice Address - Fax:773-768-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2065105273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL510204952001Medicaid
IL510204952401Medicaid
IL510204952001Medicaid