Provider Demographics
NPI:1386785152
Name:LOYOLA UNIVERSITY MEDICAL CENTER
Entity type:Organization
Organization Name:LOYOLA UNIVERSITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER INTERIM
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-233-5382
Mailing Address - Street 1:9608 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-2238
Mailing Address - Country:US
Mailing Address - Phone:708-233-5390
Mailing Address - Fax:
Practice Address - Street 1:9608 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-2238
Practice Address - Country:US
Practice Address - Phone:708-233-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540141733336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid