MEDICARE: PENNY LA RUTH WHITE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	00012637	AL
2	208000000X	Pediatrics Physician	036122437	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245254044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY LA RUTH WHITE MD

Provider Business Mailing Address
First Line	:	3 ERIE CT STE 7140
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2519
Country	:	US
Telephone Number	:	773-537-0020
Fax Number	:	773-537-0029

Provider Business Practice Location Address
First Line	:	115 N PARKSIDE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3040
Country	:	US
Telephone Number	:	773-295-3060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	01/03/2020

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Directions to “ PENNY LA RUTH WHITE MD” Practice Location

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