Provider Demographics
NPI:1124101548
Name:RUSH OTOLARYNGOLOGY HEAD AND NECK SURGERY
Entity type:Organization
Organization Name:RUSH OTOLARYNGOLOGY HEAD AND NECK SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:CALDARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-942-6100
Mailing Address - Street 1:1611 W HARRISON ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-942-6100
Mailing Address - Fax:312-942-6225
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:SUITE 550
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-942-6100
Practice Address - Fax:312-942-6225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH UNIVERSITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-21
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636656OtherBC PPO
IL01636656OtherBC PPO