Healthcare Provider Details

I. General information

NPI: 1912940198
Provider Name (Legal Business Name): MIDWEST PEDIATRIC SURGICAL ASSOCIATES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST SUITE 108
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

4400 W 95TH ST SUITE 108
OAK LAWN IL
60453-2654
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-7541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH LOEFF
Title or Position: OWNER
Credential:
Phone: 708-424-7541