Healthcare Provider Details

I. General information

NPI: 1609836931
Provider Name (Legal Business Name): LINCOLN PEDIATRIC CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5641 N LINCOLN AVE
CHICAGO IL
60659-4921
US

IV. Provider business mailing address

5641 N LINCOLN AVE
CHICAGO IL
60659-4921
US

V. Phone/Fax

Practice location:
  • Phone: 773-728-4784
  • Fax: 773-728-4759
Mailing address:
  • Phone: 773-728-4784
  • Fax: 773-728-4759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036085554
License Number StateIL

VIII. Authorized Official

Name: DR. JOANN EVIOTA RUIZ
Title or Position: DIRECTOR
Credential:
Phone: 773-728-4784