Healthcare Provider Details

I. General information

NPI: 1952346215
Provider Name (Legal Business Name): SOUTH SUBURBAN PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/22/2020
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

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

V. Phone/Fax

Practice location:
  • Phone: 708-754-3507
  • Fax:
Mailing address:
  • Phone: 708-754-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. JEANETTE BASS-JORDAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 708-754-3507