Healthcare Provider Details

I. General information

NPI: 1912295494
Provider Name (Legal Business Name): GENESIS PEDIATRIC MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 MEDITERRANEAN DR
SYCAMORE IL
60178-3144
US

IV. Provider business mailing address

1830 MEDITERRANEAN DR
SYCAMORE IL
60178-3144
US

V. Phone/Fax

Practice location:
  • Phone: 815-899-0001
  • Fax: 815-899-0002
Mailing address:
  • Phone: 815-899-0001
  • Fax: 815-899-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036097453
License Number StateIL

VIII. Authorized Official

Name: DR. MARK ALAN REGNIER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 815-899-0001