Healthcare Provider Details

I. General information

NPI: 1073053443
Provider Name (Legal Business Name): COMMUNITY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 EXECUTIVE DR
CREST HILL IL
60403-0500
US

IV. Provider business mailing address

16001 EXECUTIVE DR
CREST HILL IL
60403-0500
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-1600
  • Fax: 815-838-0556
Mailing address:
  • Phone: 815-744-1600
  • Fax: 815-838-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036093909
License Number StateIL

VIII. Authorized Official

Name: ASHOK H BHASKAR
Title or Position: OWNER
Credential: MD
Phone: 815-744-1600