Healthcare Provider Details

I. General information

NPI: 1205310356
Provider Name (Legal Business Name): BACK TO BASICS PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 HARNISH DR STE 101
ALGONQUIN IL
60102-6803
US

IV. Provider business mailing address

2403 HARNISH DR STE 101
ALGONQUIN IL
60102-6803
US

V. Phone/Fax

Practice location:
  • Phone: 224-520-0087
  • Fax:
Mailing address:
  • Phone: 224-333-0730
  • Fax: 224-333-0748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics 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. CHRISTINE POULOS
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 224-520-0087