Healthcare Provider Details

I. General information

NPI: 1578752739
Provider Name (Legal Business Name): KIDS UROLOGY. S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ # 24
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

2300 N CHILDRENS PLZ # 24
CHICAGO IL
60614-3363
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-3252
  • Fax:
Mailing address:
  • Phone: 773-880-3252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: PROF. REGINA A ALLARD
Title or Position: PRACTICE MANAGER
Credential:
Phone: 773-880-3252