Healthcare Provider Details

I. General information

NPI: 1003140500
Provider Name (Legal Business Name): PEDIATRIC GENERAL CARE & RESEARCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4527 N PULASKI RD
CHICAGO IL
60630-4415
US

IV. Provider business mailing address

4527 N PULASKI RD
CHICAGO IL
60630-4415
US

V. Phone/Fax

Practice location:
  • Phone: 773-267-7060
  • Fax: 773-267-4752
Mailing address:
  • Phone: 773-267-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036048394
License Number StateIL

VIII. Authorized Official

Name: CHANDRA M KHURANA
Title or Position: PRESIDENT
Credential: MD
Phone: 773-267-7060