Provider Demographics
NPI:1588063572
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:
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:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-9797
Mailing Address - Fax:
Practice Address - Street 1:259 E. ERIE STREET
Practice Address - Street 2:SUITE#02-220
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2661
Practice Address - Country:US
Practice Address - Phone:312-695-8150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
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