Healthcare Provider Details

I. General information

NPI: 1619333291
Provider Name (Legal Business Name): ADVOCATE CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST ROOM 0019H
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

4440 W 95TH ST ROOM 0019H
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-4561
  • Fax: 708-684-4763
Mailing address:
  • Phone: 708-684-4561
  • Fax: 708-684-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number247000065
License Number StateIL

VIII. Authorized Official

Name: JESSICA MARIE NICOLL
Title or Position: GENETIC COUNSELOR
Credential: MS, CGC
Phone: 708-684-4561