MEDICARE: LURIE CHILDREN'S MEDICAL GROUP

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1518088319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LURIE CHILDREN'S MEDICAL GROUP

Provider Business Mailing Address
First Line	:	225 E CHICAGO AVE
Second Line	:	#64
City	:	CHICAGO
State	:	IL
Zip	:	60611-2991
Country	:	US
Telephone Number	:	312-227-7200
Fax Number	:	312-227-9150

Provider Business Practice Location Address
First Line	:	467 W DEMING PL
Second Line	:	SUITE 900
City	:	CHICAGO
State	:	IL
Zip	:	60614-1881
Country	:	US
Telephone Number	:	773-327-2950
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	PAULA NOBLE
Credential	:
Telephone Number	:	312-227-7200

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/09/2013

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