Basic Information
| Provider Information | |||||||||
| NPI: | 1770656647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUHLAS | ||||||||
| AuthorizedOfficialFirstName: | EVETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STAFF PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7733272880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.