MEDICARE: CHILDREN'S MEDICAL GROUP, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036109900	IL

General Provider Information

NPI Number	:	1740483718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S MEDICAL GROUP, S.C.

Provider Business Mailing Address
First Line	:	301 N RANDALL RD
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-5961
Country	:	US
Telephone Number	:	847-658-6065
Fax Number	:	847-658-6136

Provider Business Practice Location Address
First Line	:	301 N RANDALL RD
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-5961
Country	:	US
Telephone Number	:	847-658-6065
Fax Number	:	847-658-6136

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON C TJADEN
Credential	:	MD
Telephone Number	:	847-658-6065

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	07/14/2016

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