Healthcare Provider Details

I. General information

NPI: 1790848877
Provider Name (Legal Business Name): MED-PEDS SPECIALISTS S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15614 S HARLEM AVE SUITE D
ORLAND PARK IL
60462-4402
US

IV. Provider business mailing address

15614 S HARLEM AVE SUITE D
ORLAND PARK IL
60462-4402
US

V. Phone/Fax

Practice location:
  • Phone: 708-444-0097
  • Fax: 708-444-8252
Mailing address:
  • Phone: 708-444-0097
  • Fax: 708-444-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042618236
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALICJA KRASKA
Title or Position: MANAGER
Credential: M.D.
Phone: 708-444-0097