Healthcare Provider Details

I. General information

NPI: 1982140042
Provider Name (Legal Business Name): PEDIATRIC HEALTHY HEARTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9222 S 53RD AVE
OAK LAWN IL
60453-1687
US

IV. Provider business mailing address

4700 W 95TH ST STE 206
OAK LAWN IL
60453-2574
US

V. Phone/Fax

Practice location:
  • Phone: 708-745-3499
  • Fax: 708-745-3398
Mailing address:
  • Phone: 708-745-3499
  • Fax: 708-745-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036124580
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIDA YOUSEF
Title or Position: DIRECTOR
Credential: MD
Phone: 708-745-3499