Healthcare Provider Details

I. General information

NPI: 1124053814
Provider Name (Legal Business Name): PAUL SEVERIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7154
  • Fax:
Mailing address:
  • Phone: 312-942-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-091374
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number036-091374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: