Healthcare Provider Details

I. General information

NPI: 1982958013
Provider Name (Legal Business Name): PEDIATRUST, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N WESTMORELAND RD SUITE 217
LAKE FOREST IL
60045-1674
US

IV. Provider business mailing address

2375 WATERVIEW DR STE SM100
NORTHBROOK IL
60062-6145
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-0700
  • Fax:
Mailing address:
  • Phone: 224-330-6311
  • Fax: 224-330-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN SIROTA
Title or Position: CEO
Credential: M.D.
Phone: 224-330-6300