Healthcare Provider Details

I. General information

NPI: 1760561617
Provider Name (Legal Business Name): PILSEN COMMUNITY PEDIATRICS S. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 S BLUE ISLAND AVE
CHICAGO IL
60608-3012
US

IV. Provider business mailing address

1859 S BLUE ISLAND AVE
CHICAGO IL
60608-3012
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-5455
  • Fax:
Mailing address:
  • Phone: 312-666-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GUSTAVO E OROZA-HENNERS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-666-5455