NPIMap

Organization Active NPI

South Shore Hospital Corporation

  • Psychiatric Hospital Unit
  • Chicago, IL
National Provider Identifier
1689935397
Registry record updated Aug 15, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
License
2065105 Issued in IL
Legal business name
SOUTH SHORE HOSPITAL CORPORATION
Practice address
8012 S Crandon Ave
Chicago, IL 60617-1124
Phone
(773) 356-5000
Fax
(773) 768-8154
NPI assigned
May 30, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2012

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
Psychiatric Hospital Unit 273R00000X 2065105 IL Primary

Addresses

Primary practice location

8012 S Crandon Ave
Chicago, IL 60617-1124

Mailing address

8012 S Crandon Ave
Chicago, IL 60617-1124
Phone (773) 356-5000

Other identifiers 2

IdentifierTypeStateIssuer
510204952001MedicaidIL
510204952401MedicaidIL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120815000214 IL Part A Provider - Hospital 2264322650 Practice locations: Chicago, IL

Hospital certification: CCN 14S181

Legal name
SOUTH SHORE HOSPITAL CORPORATION
Organization structure
CorporationNon-profit
Incorporated
Jan 13, 1976 in IL
Enrollment address
8012 S Crandon Ave
Chicago, IL 60617-1124
Hospital Psychiatric Unit
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).

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 10

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, Secretary Jan 1, 1976
Corporate DirectorVice President, Secretary Jan 1, 1976
Satya Ahuja Individual Corporate DirectorMedical Director Jan 1, 1993
Leslie Rogers Individual Corporate OfficerCeo Jul 1, 2022
Corporate DirectorDirector Jul 1, 2022
W-2 Managing EmployeePresident/Ceo Jul 1, 2022
Operational/Managerial ControlPresident/Ceo 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 3

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

NPI Registry JSON

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

{
    "created_epoch": "1338336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1344988800000",
    "number": "1689935397",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8012 S CRANDON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606171124",
            "telephone_number": "773-356-5000",
            "fax_number": "773-768-8154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8012 S CRANDON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606171124",
            "telephone_number": "773-356-5000",
            "fax_number": "773-768-8154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH SHORE HOSPITAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-30",
        "last_updated": "2012-08-15",
        "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": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "IL",
            "license": "2065105",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "510204952001",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "510204952401",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.