Healthcare Provider Details

I. General information

NPI: 1437133766
Provider Name (Legal Business Name): PAMELA M PERSAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W 75TH STREET SUITE 300
NAPERVILLE IL
60540
US

IV. Provider business mailing address

1331 W 75TH STREET SUITE 300
NAPERVILLE IL
60540
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-0003
  • Fax: 630-355-9822
Mailing address:
  • Phone: 630-355-0003
  • Fax: 630-355-9822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036095440
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier948157500
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: