Provider Demographics
NPI:1891052510
Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM
Entity Type:Organization
Organization Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM
Other - Org Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM KELLOGG GB PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:WELDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-570-5099
Mailing Address - Street 1:1301 CENTRAL ST RM 222
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1613
Mailing Address - Country:US
Mailing Address - Phone:847-570-2000
Mailing Address - Fax:
Practice Address - Street 1:2180 PFINGSTEN RD STE 1008
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1339
Practice Address - Country:US
Practice Address - Phone:847-503-1206
Practice Address - Fax:847-503-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540178873336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILN/AMedicaid
2134685OtherPK