Healthcare Provider Details

I. General information

NPI: 1134243868
Provider Name (Legal Business Name): PEDIATRIC CRITICAL CARE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

P O BOX 2698
CAROL STREAM IL
60132-2698
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax: 847-723-2325
Mailing address:
  • Phone: 847-723-2210
  • Fax: 847-723-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: SURESH HAVALAD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-723-2210