Healthcare Provider Details

I. General information

NPI: 1790280881
Provider Name (Legal Business Name): LAUREN LANDERHOLM MILLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 02/14/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 N RAVENSWOOD AVE
CHICAGO IL
60640-5802
US

IV. Provider business mailing address

1301 W DEVON AVE
CHICAGO IL
60660-1329
US

V. Phone/Fax

Practice location:
  • Phone: 773-432-6570
  • Fax:
Mailing address:
  • Phone: 773-751-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.156536
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: