Healthcare Provider Details

I. General information

NPI: 1154002202
Provider Name (Legal Business Name): DANIEL LAVERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

909 N LEAVITT ST APT 3F
CHICAGO IL
60622-7114
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7100
  • Fax:
Mailing address:
  • Phone: 815-274-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28290977A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041455072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: