Healthcare Provider Details

I. General information

NPI: 1043913304
Provider Name (Legal Business Name): RAWAN WAGIEALLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 09/26/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL 225 EAST CHICAGO AVENUE
CHICAGO IL
60611
US

IV. Provider business mailing address

118 MOUNT VERNON STREET APARTMENT 1
BOSTON MA
02108
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 857-829-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: