Healthcare Provider Details

I. General information

NPI: 1801038302
Provider Name (Legal Business Name): CHILDREN'S MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ # 18
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

117 FERSON AVE
IOWA CITY IA
52246-3505
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-4302
  • Fax:
Mailing address:
  • Phone: 816-807-3883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LINDA GROBLE
Title or Position: RESIDENCY PROGRAM COORDINATOR
Credential:
Phone: 773-880-4302