MEDICARE: NORTHSIDE-SUBURBAN PEDIATRIC ASSOCIATES, 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	174400000X	Specialist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01615555	OTHER	IL	BLUE SHIELD PROVIDER #

General Provider Information

NPI Number	:	1902802770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE-SUBURBAN PEDIATRIC ASSOCIATES, S.C.

Provider Business Mailing Address
First Line	:	4801 W PETERSON AVE
Second Line	:	STE 506
City	:	CHICAGO
State	:	IL
Zip	:	60646-5795
Country	:	US
Telephone Number	:	773-777-5437
Fax Number	:	773-777-7567

Provider Business Practice Location Address
First Line	:	4801 W PETERSON AVE
Second Line	:	STE 506
City	:	CHICAGO
State	:	IL
Zip	:	60646-5795
Country	:	US
Telephone Number	:	773-777-5437
Fax Number	:	773-777-7567

Authorized Official
Title or Position	:	ADMINISTRATOR/MANAGER
Name	:	MARY DEUTSCH
Credential	:
Telephone Number	:	773-777-5437

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	08/22/2020

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