Basic Information
| Provider Information | |||||||||
| NPI: | 1861015521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTON CHILDREN'S MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | NORTON CHILDREN'S EYE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4803 OLYMPIA PARK PLZ STE 1100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402413068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725134 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | GAST | ||||||||
| AuthorizedOfficialFirstName: | SHELLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYST VP MNGD CARE & PAYOR STRAT | ||||||||
| AuthorizedOfficialTelephone: | 5022725335 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 152W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0110X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.