Provider Demographics
NPI:1447830997
Name:BURR RIDGE BIRTH CENTER, LLC
Entity type:Organization
Organization Name:BURR RIDGE BIRTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEGAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-793-2676
Mailing Address - Street 1:7000 S COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6973
Mailing Address - Country:US
Mailing Address - Phone:630-793-2676
Mailing Address - Fax:630-793-2677
Practice Address - Street 1:7000 S COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6973
Practice Address - Country:US
Practice Address - Phone:630-793-2676
Practice Address - Fax:630-793-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid