Healthcare Provider Details

I. General information

NPI: 1770568016
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF THE NW MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5057 SHORELINE RD
LAKE BARRINGTON IL
60010-1700
US

IV. Provider business mailing address

5057 SHORELINE RD
LAKE BARRINGTON IL
60010-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-5005
  • Fax: 847-381-5036
Mailing address:
  • Phone: 847-381-5005
  • Fax: 847-381-5036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CHARLES M BRAVERMAN
Title or Position: HEAD DOCTOR
Credential: MD
Phone: 847-381-5005