Healthcare Provider Details

I. General information

NPI: 1124123146
Provider Name (Legal Business Name): PEDIATRIC FACULTY FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ BOX 62
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

1731 N MARCEY ST FL ST-4TH BOX 118
CHICAGO IL
60614-5373
US

V. Phone/Fax

Practice location:
  • Phone: 312-573-4512
  • Fax: 312-573-8400
Mailing address:
  • Phone: 312-573-4512
  • Fax: 312-573-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA M LENZ
Title or Position: DIRECTOR, PHYSICIAN BILLING
Credential:
Phone: 312-573-4512