Provider Demographics
NPI:1124123146
Name:PEDIATRIC FACULTY FOUNDATION, INC
Entity type:Organization
Organization Name:PEDIATRIC FACULTY FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHYSICIAN BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-573-4512
Mailing Address - Street 1:1731 N MARCEY ST FL ST-4TH
Mailing Address - Street 2:BOX 118
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5373
Mailing Address - Country:US
Mailing Address - Phone:312-573-4512
Mailing Address - Fax:312-573-8400
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX 62
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:312-573-4512
Practice Address - Fax:312-573-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208167Medicare ID - Type Unspecified