Healthcare Provider Details

I. General information

NPI: 1124080155
Provider Name (Legal Business Name): MARY LYNN KREITER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 09/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHILDRENS PLAZA BOX 54
CHICAGO IL
60614
US

IV. Provider business mailing address

2300 CHILDRENS PLAZA BOX 54
CHICAGO IL
60614
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-4440
  • Fax: 773-880-4063
Mailing address:
  • Phone: 773-880-4440
  • Fax: 773-880-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number036074037
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: