MEDICARE: LURIE CHILDREN'S MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207ZP0213X	Pediatric Pathology Physician
2	2084P0804X	Child & Adolescent Psychiatry Physician
3	2085N0700X	Neuroradiology Physician
4	2085P0229X	Pediatric Radiology Physician
5	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1992758544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LURIE CHILDREN'S MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	225 E CHICAGO AVE
Second Line	:	BOX 118
City	:	CHICAGO
State	:	IL
Zip	:	60611-2991
Country	:	US
Telephone Number	:	312-227-6412
Fax Number	:	312-227-9409

Provider Business Practice Location Address
First Line	:	225 E CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2991
Country	:	US
Telephone Number	:	800-543-7362
Fax Number	:

Authorized Official
Title or Position	:	DIR CREDENTIALING & ENROLLMENT
Name	:	MS. CHERYL WITHERS
Credential	:	CPCS
Telephone Number	:	312-227-6415

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	08/24/2022

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