Healthcare Provider Details

I. General information

NPI: 1912203209
Provider Name (Legal Business Name): MATERNAL AND CHILD MEDICAL CARE, S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 W ARMY TRAIL RD SUITE 104
ADDISON IL
60101-1478
US

IV. Provider business mailing address

2055 WEST ARMY TRAIL ROAD SUITE 104
ADDISON IL
60101
US

V. Phone/Fax

Practice location:
  • Phone: 847-650-1452
  • Fax: 224-535-7260
Mailing address:
  • Phone: 847-650-1452
  • Fax: 224-535-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ORAWAN SUKAVACHANA
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 847-650-1452