Healthcare Provider Details

I. General information

NPI: 1043498041
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 EAST 75TH STREET SUITE 101
CHICAGO IL
60649-3646
US

IV. Provider business mailing address

2011 EAST 75TH STREET SUITE 101
CHICAGO IL
60649-3646
US

V. Phone/Fax

Practice location:
  • Phone: 773-288-4824
  • Fax: 773-288-3995
Mailing address:
  • Phone: 773-288-4824
  • Fax: 773-288-3995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036037561
License Number StateIL

VIII. Authorized Official

Name: MRS. BILLIE WRIGHT ADAMS
Title or Position: PRIMARY CARE PHYSICIAN
Credential: MD
Phone: 773-288-4824