Provider Demographics
NPI:1982958013
Name:PEDIATRUST, L.L.C.
Entity Type:Organization
Organization Name:PEDIATRUST, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIROTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-330-6300
Mailing Address - Street 1:2375 WATERVIEW DR STE SM100
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6145
Mailing Address - Country:US
Mailing Address - Phone:224-330-6311
Mailing Address - Fax:224-330-6325
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE 217
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-615-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty