Healthcare Provider Details

I. General information

NPI: 1649353970
Provider Name (Legal Business Name): MED PEDS ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N WALL ST STE P520
KANKAKEE IL
60901-3493
US

IV. Provider business mailing address

375 N WALL ST STE P520
KANKAKEE IL
60901-3493
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-0194
  • Fax: 815-933-1444
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number036074737
License Number StateIL

VIII. Authorized Official

Name: DIRENDIA SHACKELFORD
Title or Position: MANAGED CARE SPECIALIST
Credential:
Phone: 800-654-0889