Provider Demographics
NPI:1578941340
Name:SYMPHONY JACKSON SQUARE LLC
Entity type:Organization
Organization Name:SYMPHONY JACKSON SQUARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-745-6212
Mailing Address - Street 1:7257 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1810
Mailing Address - Country:US
Mailing Address - Phone:847-745-6212
Mailing Address - Fax:
Practice Address - Street 1:5130 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4332
Practice Address - Country:US
Practice Address - Phone:773-921-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
14-5661OtherMEDICARE ID