Provider Demographics
NPI:1609836931
Name:LINCOLN PEDIATRIC CENTER, PC
Entity Type:Organization
Organization Name:LINCOLN PEDIATRIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:EVIOTA
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-728-4784
Mailing Address - Street 1:5641 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4921
Mailing Address - Country:US
Mailing Address - Phone:773-728-4784
Mailing Address - Fax:773-728-4759
Practice Address - Street 1:5641 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4921
Practice Address - Country:US
Practice Address - Phone:773-728-4784
Practice Address - Fax:773-728-4759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085554Medicaid