Provider Demographics
NPI:1063955078
Name:LURIE CHILDRENS PEDIATRIC ANESTHESIA ASSOCIATES
Entity type:Organization
Organization Name:LURIE CHILDRENS PEDIATRIC ANESTHESIA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF CREDENTIALING & ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:312-227-6415
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:BOX 118
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6415
Mailing Address - Fax:312-227-9409
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6415
Practice Address - Fax:312-227-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty