Healthcare Provider Details

I. General information

NPI: 1194910729
Provider Name (Legal Business Name): FREEPORT PEDIATRICS, S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 KIWANIS DR
FREEPORT IL
61032-7119
US

IV. Provider business mailing address

750 KIWANIS DR
FREEPORT IL
61032-7119
US

V. Phone/Fax

Practice location:
  • Phone: 815-235-9233
  • Fax: 815-235-9254
Mailing address:
  • Phone: 815-235-9233
  • Fax: 815-235-9254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PRASAD THOMAS
Title or Position: PEDIATRICIAN
Credential: M.D
Phone: 815-235-9233