=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205433042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIRTH CENTER OF CHICAGO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 03/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3832 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-232-2293
-----------------------------------------------------
Fax | 773-232-2299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3832 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-232-2293
-----------------------------------------------------
Fax | 773-232-2299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LAURA WIEGAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-361-9199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QB0400X
-----------------------------------------------------
Taxonomy Name | Birthing Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------