Healthcare Provider Details

I. General information

NPI: 1437458064
Provider Name (Legal Business Name): PEDIATRIC MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W CENTRAL RD SUITE 1
MT PROSPECT IL
60056-2379
US

IV. Provider business mailing address

902 FLORENCE DR
PARK RIDGE IL
60068-2108
US

V. Phone/Fax

Practice location:
  • Phone: 847-222-0999
  • Fax: 847-203-0203
Mailing address:
  • Phone: 224-616-9749
  • Fax: 630-894-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036083477
License Number StateIL

VIII. Authorized Official

Name: DR. GISELA GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 224-616-9749