Provider Demographics
NPI:1053377473
Name:CHICAGO WOMEN'S HEALTH GROUP AT NORTHWESTERN
Entity type:Organization
Organization Name:CHICAGO WOMEN'S HEALTH GROUP AT NORTHWESTERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-943-0282
Mailing Address - Street 1:333 E SUPERIOR ST
Mailing Address - Street 2:SUITE 444
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2654
Mailing Address - Country:US
Mailing Address - Phone:312-943-0282
Mailing Address - Fax:312-943-0284
Practice Address - Street 1:333 E SUPERIOR ST
Practice Address - Street 2:SUITE 444
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:312-943-0282
Practice Address - Fax:312-943-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006984174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-20273OtherBLUE CROSS BLUE SHIELD
IL208441Medicare ID - Type Unspecified