Healthcare Provider Details

I. General information

NPI: 1619021359
Provider Name (Legal Business Name): CHILDRENS MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2731 HARRISON ST
EVANSTON IL
60201-1215
US

IV. Provider business mailing address

2300 N CHILDRENS PLZ
CHICAGO IL
60614-3363
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-9404
  • Fax:
Mailing address:
  • Phone: 773-880-4530
  • Fax: 773-880-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number147.000686
License Number StateIL

VIII. Authorized Official

Name: MRS. NANCY G OTWELL
Title or Position: SENIOR PEDIATRIC AUDIOLOGIST
Credential: MSCCA
Phone: 773-975-8650