Provider Demographics
NPI:1013418854
Name:WILLOW PEDIATRICS AND LACTATION
Entity Type:Organization
Organization Name:WILLOW PEDIATRICS AND LACTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CHIEF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-869-9556
Mailing Address - Street 1:2518 W ADDISON ST APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5953
Mailing Address - Country:US
Mailing Address - Phone:312-697-9307
Mailing Address - Fax:
Practice Address - Street 1:1430 W. FILLMORE ST. #1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-869-9556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036144763208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty