Healthcare Provider Details

I. General information

NPI: 1174459937
Provider Name (Legal Business Name): PROMED PREFERRED IL 4 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 W IRVING PARK RD
CHICAGO IL
60613-1922
US

IV. Provider business mailing address

1449 W IRVING PARK RD
CHICAGO IL
60613-1922
US

V. Phone/Fax

Practice location:
  • Phone: 872-315-3375
  • Fax: 855-654-6385
Mailing address:
  • Phone: 872-315-3375
  • Fax: 855-654-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LAUREN DUANE BUCKINGHAM
Title or Position: MANAGER
Credential: PA-C
Phone: 616-325-5039