=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134813835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WIBETO PRACTICE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1820 W WEBSTER AVE STE 304
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-4892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-253-9002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1820 W. WEBSTER UNITS 304 AND 307
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY LURIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-253-9002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------