Basic Information
| Provider Information | |||||||||
| NPI: | 1376805374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAINE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELAN | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082362673 | ||||||||
| FaxNumber: | 7084095179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 W HARRISON ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124322300 | ||||||||
| FaxNumber: | 7084095179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | APPLIED FOR | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1912218850 | 01 | IL | NPI GROUP PRACTICE | OTHER |