Provider Demographics
NPI:1518055524
Name:LARABIDA CHILDRENS HOSPITAL
Entity Type:Organization
Organization Name:LARABIDA CHILDRENS HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO / VP ADMINISTRATION
Authorized Official - Prefix:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0003012281PC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281PC2000XHospitalsChronic Disease HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========401Medicaid