Healthcare Provider Details

I. General information

NPI: 1710110473
Provider Name (Legal Business Name): FOX RIVER PEDIATRICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 09/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 US HIGHWAY 34 SUITE 3
PLANO IL
60545-9824
US

IV. Provider business mailing address

11000 US HIGHWAY 34 SUITE 3
PLANO IL
60545-9824
US

V. Phone/Fax

Practice location:
  • Phone: 630-552-9852
  • Fax: 630-552-9857
Mailing address:
  • Phone: 630-552-9852
  • Fax: 630-552-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-112854
License Number StateIL

VIII. Authorized Official

Name: AYEZAH MIR
Title or Position: OWNER
Credential: MD
Phone: 630-926-4471