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General NPI Number Information
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NPI Number | 1295822120
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Entity Type | Organization
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Legal Business Name | BLOOMINGDALE GENERAL PEDIATRICS
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 109 FAIRFIELD WAY SUITE 103
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1583
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Country | US
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Telephone | 630-894-3250
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Fax | 630-894-3280
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Provider Business Mailing Address
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Address Line | 109 FAIRFIELD WAY SUITE 103
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1583
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Country | US
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Telephone | 630-894-3250
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Fax | 630-894-3280
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Authorized Official
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Title or Position | PRESIDENT
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Name | EDWIN PASCUAL
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Credential | M.D
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Telephone | 630-894-3250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036067770
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License Number State | IL
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