Healthcare Provider Details

I. General information

NPI: 1689729261
Provider Name (Legal Business Name): THE NORTHWESTERN CHILDREN'S PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR 123
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

680 N LAKE SHORE DR 123
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-5515
  • Fax: 312-642-0753
Mailing address:
  • Phone: 312-642-5515
  • Fax: 312-642-0753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARC WEISSBLUTH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-642-5515