Healthcare Provider Details

I. General information

NPI: 1366874356
Provider Name (Legal Business Name): RAVENSWOOD PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W WILSON AVE STE 6116
CHICAGO IL
60640
US

IV. Provider business mailing address

1945 W WILSON AVE STE 6116
CHICAGO IL
60640-5259
US

V. Phone/Fax

Practice location:
  • Phone: 872-208-6257
  • Fax:
Mailing address:
  • Phone: 872-208-6257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036065805
License Number StateIL

VIII. Authorized Official

Name: TODD J OCHS
Title or Position: OWNER
Credential: M.D.
Phone: 872-208-6257