Basic Information
| Provider Information | |||||||||
| NPI: | 1245746213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGOLAND UNIVERSITY PEDIATRIC SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13400 S ROUTE 59 STE 116-208 | ||||||||
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| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605855826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304241122 | ||||||||
| FaxNumber: | 6303962677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 12/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | NOBLE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6304241122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.