Provider Demographics
NPI:1700075454
Name:EVOLVE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:EVOLVE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-349-3030
Mailing Address - Street 1:10743 W 159TH ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4531
Mailing Address - Country:US
Mailing Address - Phone:708-349-3030
Mailing Address - Fax:708-460-1459
Practice Address - Street 1:10743 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4531
Practice Address - Country:US
Practice Address - Phone:708-349-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1622748OtherBLUE SHIELD