Healthcare Provider Details

I. General information

NPI: 1801058086
Provider Name (Legal Business Name): CHILDREN'S MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S MICHIGAN AVE APT 810
CHICAGO IL
60605-3268
US

IV. Provider business mailing address

1250 S MICHIGAN AVE APT 810
CHICAGO IL
60605-3268
US

V. Phone/Fax

Practice location:
  • Phone: 773-991-9108
  • Fax:
Mailing address:
  • Phone: 773-991-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUE M PARK
Title or Position: NURSE PRACTITIONER
Credential: APN
Phone: 773-880-4006