Healthcare Provider Details

I. General information

NPI: 1871930693
Provider Name (Legal Business Name): SHRINERS HOSPITALS FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 N OAK PARK AVE
CHICAGO IL
60707-3351
US

IV. Provider business mailing address

PO BOX 8500 LOCKBOX #7642
PHILADELPHIA PA
19178-7642
US

V. Phone/Fax

Practice location:
  • Phone: 773-385-5400
  • Fax: 773-385-5453
Mailing address:
  • Phone: 773-385-5445
  • Fax: 773-385-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERRY G. GANTT
Title or Position: PRESIDENT
Credential:
Phone: 218-281-0300