Basic Information
| Provider Information | |||||||||
| NPI: | 1780142778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT SINAI PEDIATRIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 W POLK ST STE 220C | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123723 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2653 W OGDEN AVE | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735222010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDRLE | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3128644649 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COOK COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.