Healthcare Provider Details

I. General information

NPI: 1497821706
Provider Name (Legal Business Name): CHILDREN'S MEMORIAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ #64
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

2300 N CHILDRENS PLZ #64
CHICAGO IL
60614-3363
US

V. Phone/Fax

Practice location:
  • Phone: 312-573-4515
  • Fax: 312-573-8405
Mailing address:
  • Phone: 312-573-4515
  • Fax: 312-573-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA LENZ
Title or Position: DIRECTOR
Credential:
Phone: 312-573-4512