Provider Demographics
NPI:1518033836
Name:LURIE CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:LURIE CHILDREN'S MEDICAL GROUP
Other - Org Name:LCMG SPECIALTY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LENZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:312-227-7121
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:#64
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-7200
Mailing Address - Fax:312-227-9105
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1637685OtherBCBS
IL215528Medicare PIN