Healthcare Provider Details

I. General information

NPI: 1033299649
Provider Name (Legal Business Name): LAGRANGE PEDIATRICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 WILLOW SPRINGS ROAD
LA GRANGE IL
60525
US

IV. Provider business mailing address

4727 WILLOW SPRINGS ROAD
LA GRANGE IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 708-588-0088
  • Fax: 708-588-0588
Mailing address:
  • Phone: 708-588-0088
  • Fax: 708-588-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK C MATRAY
Title or Position: PHYSICIAN PRESIDENT
Credential: MD
Phone: 708-588-0088