Healthcare Provider Details

I. General information

NPI: 1245746213
Provider Name (Legal Business Name): CHICAGOLAND UNIVERSITY PEDIATRIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

13400 S ROUTE 59 STE 116-208
PLAINFIELD IL
60585-5826
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3000
  • Fax:
Mailing address:
  • Phone: 630-424-1122
  • Fax: 630-396-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES NOBLE
Title or Position: REVENUE MANAGER
Credential:
Phone: 630-424-1122