Basic Information
| Provider Information | |||||||||
| NPI: | 1275693756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N CHILDRENS PLZ | ||||||||
| Address2: | BOX 142 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606143363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733272880 | ||||||||
| FaxNumber: | 7733270547 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 N CHILDRENS PLZ | ||||||||
| Address2: | BOX 142 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606143363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733272880 | ||||||||
| FaxNumber: | 7733270547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | SHANE | ||||||||
| AuthorizedOfficialTitleorPosition: | SPEECH-LANGUAGE PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7733272880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.S., CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.