Healthcare Provider Details

I. General information

NPI: 1407032022
Provider Name (Legal Business Name): CHICAGOLAND COMMUNITY PEDIATRIC CARDIOLOGY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 07/25/2024
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 N CALIFORNIA AVE SUITE 230
CHICAGO IL
60618-4677
US

IV. Provider business mailing address

2923 N CALIFORNIA AVE SUITE 230
CHICAGO IL
60618-4677
US

V. Phone/Fax

Practice location:
  • Phone: 312-951-5800
  • Fax: 312-951-5816
Mailing address:
  • Phone: 312-951-5800
  • Fax: 312-951-5816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number042007521
License Number StateIL

VIII. Authorized Official

Name: DEBRA SCHAFFER
Title or Position: BILLING MANAGER
Credential:
Phone: 630-217-7799