Provider Demographics
NPI:1124080155
Name:KREITER, MARY LYNN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:KREITER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:BOX 54
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-880-4440
Mailing Address - Fax:773-880-4063
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:BOX 54
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-4440
Practice Address - Fax:773-880-4063
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360740372080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074037Medicaid
ILK11139Medicare ID - Type Unspecified
IL036074037Medicaid