Healthcare Provider Details

I. General information

NPI: 1780633313
Provider Name (Legal Business Name): FGM PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8711 W CERMAK RD
NORTH RIVERSIDE IL
60546-1166
US

IV. Provider business mailing address

PO BOX 967
TINLEY PARK IL
60477-0967
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-7979
  • Fax: 708-442-8574
Mailing address:
  • Phone: 708-532-6029
  • Fax: 708-532-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARC A FREED
Title or Position: CO-OWNER
Credential: DO
Phone: 708-442-7979