Provider Demographics
NPI:1770992448
Name:NORTHWESTERN MEDICAL FACULTY FOUNDATION
Entity type:Organization
Organization Name:NORTHWESTERN MEDICAL FACULTY FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP,CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:01041973
Authorized Official - Phone:312-926-1599
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE# 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:312-695-9797
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:SUITE# 1297
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:847-295-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0597400003Medicare NSC