Healthcare Provider Details

I. General information

NPI: 1134590995
Provider Name (Legal Business Name): LURIE CHILDRENS PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 09/28/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N HALSTED ST SUITE 402
CHICAGO IL
60642-2605
US

IV. Provider business mailing address

225 E CHICAGO AVE # 118
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-279-8900
  • Fax:
Mailing address:
  • Phone: 312-227-6415
  • Fax: 312-227-9409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL WITHERS
Title or Position: DIRECTOR
Credential:
Phone: 312-227-6415