Healthcare Provider Details

I. General information

NPI: 1518033836
Provider Name (Legal Business Name): LURIE CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/28/2014
Certification Date:
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 #64
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 312-227-7200
  • Fax: 312-227-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA LENZ
Title or Position: DIRECTOR
Credential: MBA
Phone: 312-227-7121