Healthcare Provider Details

I. General information

NPI: 1912930769
Provider Name (Legal Business Name): DOWNERS GROVE PEDIATRICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 S. MAIN STREET SUITE 201
DOWNERS GROVE IL
60516-3493
US

IV. Provider business mailing address

6840 S. MAIN STREET SUITE 201
DOWNERS GROVE IL
60516-3493
US

V. Phone/Fax

Practice location:
  • Phone: 630-852-4551
  • Fax: 630-451-0131
Mailing address:
  • Phone: 630-852-4551
  • Fax: 630-451-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number042001840
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042-001840
License Number StateIL

VIII. Authorized Official

Name: DR. EMILIO CABANA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 630-852-4551