Provider Demographics
NPI:1396250304
Name:JACKSON PARK HOSPITAL FOUNDATION
Entity type:Organization
Organization Name:JACKSON PARK HOSPITAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF SPECIAL PROJECTS
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-947-7701
Mailing Address - Street 1:7531 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3954
Mailing Address - Country:US
Mailing Address - Phone:773-947-7500
Mailing Address - Fax:
Practice Address - Street 1:7531 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:773-947-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON PARK HOSPITAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-13
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001115273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid