Provider Demographics
NPI:1114492055
Name:LA RABIDA CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:LA RABIDA CHILDREN'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO / VP ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RENFREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-753-8630
Mailing Address - Street 1:6501 S PROMONTORY DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1003
Mailing Address - Country:US
Mailing Address - Phone:773-363-6700
Mailing Address - Fax:773-363-6315
Practice Address - Street 1:6501 S PROMONTORY DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1003
Practice Address - Country:US
Practice Address - Phone:773-363-6700
Practice Address - Fax:773-363-6315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA RABIDA CHILDREN'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========401Medicaid