Healthcare Provider Details

I. General information

NPI: 1114492055
Provider Name (Legal Business Name): LA RABIDA CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 S PROMONTORY DR
CHICAGO IL
60649-1003
US

IV. Provider business mailing address

6501 S PROMONTORY DR
CHICAGO IL
60649-1003
US

V. Phone/Fax

Practice location:
  • Phone: 773-363-6700
  • Fax: 773-363-6315
Mailing address:
  • Phone: 773-363-6700
  • Fax: 773-363-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MARK RENFREE
Title or Position: CFO / VP ADMINISTRATION
Credential:
Phone: 773-753-8630