Healthcare Provider Details

I. General information

NPI: 1285317859
Provider Name (Legal Business Name): MIDWAY PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 W 55TH ST
CHICAGO IL
60632-4642
US

IV. Provider business mailing address

4254 W 55TH ST
CHICAGO IL
60632-4642
US

V. Phone/Fax

Practice location:
  • Phone: 773-358-2520
  • Fax: 773-582-2772
Mailing address:
  • Phone: 773-358-2520
  • Fax: 773-582-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAELLE ROJAS
Title or Position: CO-OWNER
Credential:
Phone: 773-582-5200