=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013183706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARTNERS IN CHILDREN'S HEALTH,S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 HAUSER ROSS DR SUITE #350
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-754-5010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 HAUSER ROSS DR SUITE #350
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-754-5010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PUSHPA K MAMTANI
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 815-754-5010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 036064091
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------