Healthcare Provider Details

I. General information

NPI: 1346230232
Provider Name (Legal Business Name): TINLEY PARK PEDIATRIC ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6703 159TH ST SUITE 115
TINLEY PARK IL
60477-1781
US

IV. Provider business mailing address

PO BOX 789
MATTESON IL
60443-0789
US

V. Phone/Fax

Practice location:
  • Phone: 708-342-7032
  • Fax: 708-342-7085
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DENICE D COOK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-342-7032