Healthcare Provider Details

I. General information

NPI: 1235244047
Provider Name (Legal Business Name): CHARLES EDWARD LAURITO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST SUITE 3200, MAIL CODE 515
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

430 FOX MEADOW DR
NORTHFIELD IL
60093-4301
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4020
  • Fax:
Mailing address:
  • Phone: 847-881-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: