NPIMap

Organization Active NPI

South Shore Hospital Corporation

  • General Acute Care Hospital
  • Chicago, IL
National Provider Identifier
1053391359
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
1706462 Issued in IL
Legal business name
SOUTH SHORE HOSPITAL CORPORATION
Practice address
8012 S Crandon Ave
Finance Department
Chicago, IL 60617-1124
Phone
(773) 356-5312
Fax
(773) 768-8154
NPI assigned
Jan 20, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Timothy Arthur Caveney
Title
Chief Financial Officer
Phone
(773) 356-5312

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 1706462 IL Primary

Addresses

Primary practice location

8012 S Crandon Ave
Finance Department
Chicago, IL 60617-1124

Mailing address

8012 S Crandon Ave
Finance Department
Chicago, IL 60617-1124
Phone (773) 356-5312

Other identifiers 1

IdentifierTypeStateIssuer
510204952001MedicaidIL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050406000625 IL Part B Supplier - Clinic/Group Practice 2264322650 Receives reassigned benefits from 1 practitioner
Practice locations: Chicago, IL
O20110119000232 IL Part A Provider - Hospital 2264322650 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053391359. Details of each certification follow.

Hospital certification: CCN 140181

Legal name
SOUTH SHORE HOSPITAL CORPORATION
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Dec 3, 2021
Beds
137
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Jan 13, 1976 in IL
Enrollment address
8012 S Crandon Ave
Chicago, IL 60617-1124
Other Hospital Practice Location
Hospital subgroups
Acute care, Psychiatric

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospital

Medicare Care Compare
Listed as
South Shore HospitalCCN 140181 · All quality measures
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
South Shore Hospital4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Todd H Stroger Individual Corporate OfficerTreasurer of the Board Jul 17, 2013
Corporate DirectorTreasurer of the Board Jan 1, 1996
Joyce Johnson-Miller Individual Corporate DirectorDirector Mar 22, 2022
Olusegun Apata Individual Corporate DirectorDirector Jan 19, 2021
Jason Chen Individual Corporate DirectorDirector Jan 15, 2019
Betty L Johnson Individual Corporate DirectorBoard Director Apr 16, 2014
Lupe Valadez Individual Corporate OfficerVice President Jan 1, 1976
Corporate DirectorSecretary of the Board Jan 1, 1976
Leslie Rogers Individual Corporate OfficerChief Executive Officer Jul 1, 2022
W-2 Managing EmployeeChief Executive Officer Jul 1, 2022
Blair Dietrich Individual Corporate DirectorBoard Director Jul 20, 2016
Linda Sanders Individual Corporate DirectorDirector Mar 22, 2022

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 39

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 39

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1137715200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1053391359",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8012 S CRANDON AVE",
            "address_2": "FINANCE DEPARTMENT",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606171124",
            "telephone_number": "773-356-5312",
            "fax_number": "773-768-8154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8012 S CRANDON AVE",
            "address_2": "FINANCE DEPARTMENT",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606171124",
            "telephone_number": "773-356-5312",
            "fax_number": "773-768-8154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH SHORE HOSPITAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-20",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "CAVENEY",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "ARTHUR",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "773-356-5312",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "IL",
            "license": "1706462",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "510204952001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.