Healthcare Provider Details

I. General information

NPI: 1922435890
Provider Name (Legal Business Name): PEDIATRIC URGENT CARE OF ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2013
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 REMINGTON BLVD SUITE K
BOLINGBROOK IL
60440-3656
US

IV. Provider business mailing address

5611 COLLEYVILLE BLVD STE 100
COLLEYVILLE TX
76034-6069
US

V. Phone/Fax

Practice location:
  • Phone: 630-487-1556
  • Fax:
Mailing address:
  • Phone: 817-485-6000
  • Fax: 214-276-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036091219
License Number StateIL

VIII. Authorized Official

Name: MR. GERARDO REYES
Title or Position: OWNER
Credential: M.D.
Phone: 630-487-1556