Healthcare Provider Details

I. General information

NPI: 1003100942
Provider Name (Legal Business Name): CICERO PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5307 W CERMAK RD
CICERO IL
60804-2817
US

IV. Provider business mailing address

5307 W CERMAK RD
CICERO IL
60804-2817
US

V. Phone/Fax

Practice location:
  • Phone: 708-477-6700
  • Fax: 708-477-6704
Mailing address:
  • Phone: 708-477-6700
  • Fax: 708-477-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036120132
License Number StateIL

VIII. Authorized Official

Name: KHUDSIA RANA IRFAN
Title or Position: OWNER
Credential: M.D.,
Phone: 630-797-1411