Provider Demographics
NPI:1942561469
Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM
Entity Type:Organization
Organization Name:NORTHSHORE UNIVERSITY HEALTHSYSTEM
Other - Org Name:NORTHSHORE UNIV HEALTHSYSTEM- KELLOGG HP 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 1:757 PARK AVE W RM 1851
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2556
Practice Address - Country:US
Practice Address - Phone:847-926-6560
Practice Address - Fax:847-926-5390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540179423336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135737OtherPK
ILN/AMedicaid