Healthcare Provider Details

I. General information

NPI: 1518064716
Provider Name (Legal Business Name): LURIE CHILDREN'S MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 312-227-6412
  • Fax: 312-227-9409
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 CREDENTIALING ENROLLMENT
Credential:
Phone: 312-227-6415