Basic Information
| Provider Information | |||||||||
| NPI: | 1205458874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOTTKE | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | CONROY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1645 W JACKSON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129422200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1645 W JACKSON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129422200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2020 | ||||||||
| LastUpdateDate: | 05/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125076312 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.