Healthcare Provider Details

I. General information

NPI: 1609957018
Provider Name (Legal Business Name): 123 PEDIATRICS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 S EOLA RD SUITE 102
AURORA IL
60503-6489
US

IV. Provider business mailing address

2380 S EOLA RD SUITE 102
AURORA IL
60503-6489
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-7337
  • Fax: 630-978-1341
Mailing address:
  • Phone: 630-978-7337
  • Fax: 630-978-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN LUE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-978-7337