Provider Demographics
NPI:1093143125
Name:LAWRENCE H ITELD, MD, LLC
Entity Type:Organization
Organization Name:LAWRENCE H ITELD, MD, LLC
Other - Org Name:LINCOLN PARK PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:HAL
Authorized Official - Last Name:ITELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-757-4505
Mailing Address - Street 1:939 W NORTH AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:939 W NORTH AVE STE 600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7138
Practice Address - Country:US
Practice Address - Phone:312-757-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108014208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI10385Medicare UPIN