Provider Demographics
NPI:1134590995
Name:LURIE CHILDRENS PRIMARY CARE LLC
Entity type:Organization
Organization Name:LURIE CHILDRENS PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-227-6415
Mailing Address - Street 1:225 E CHICAGO AVE # 118
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6415
Mailing Address - Fax:312-227-9409
Practice Address - Street 1:1460 N HALSTED ST
Practice Address - Street 2:SUITE 402
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2605
Practice Address - Country:US
Practice Address - Phone:312-279-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDRENS HOSPITAL OF CHICAGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-19
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty