Healthcare Provider Details

I. General information

NPI: 1346764438
Provider Name (Legal Business Name): SUBURBAN PEDIATRICS MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 W 10TH ST
CHICAGO HEIGHTS IL
60411-2000
US

IV. Provider business mailing address

3037 CARMEL DR
FLOSSMOOR IL
60422-2263
US

V. Phone/Fax

Practice location:
  • Phone: 708-754-3507
  • Fax: 708-754-6153
Mailing address:
  • Phone: 773-983-3948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036124598
License Number StateIL

VIII. Authorized Official

Name: DR. CARLETHA CAROL HUGHES
Title or Position: OWNER
Credential: MD
Phone: 708-754-3507