Provider Demographics
NPI:1518064716
Name:PEDIATRIC FACULTY FOUNDATION INC
Entity Type:Organization
Organization Name:PEDIATRIC FACULTY FOUNDATION INC
Other - Org Name:PFF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF CREDENTIALING & ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:312-227-6415
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:BOX 118
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6412
Mailing Address - Fax:312-227-9409
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:312-227-6412
Practice Address - Fax:312-227-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid