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General NPI Number Information
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NPI Number | 1346764438
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Entity Type | Organization
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Legal Business Name | SUBURBAN PEDIATRICS MEDICAL CENTER, LLC
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Dates
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Enumeration Date | 07/31/2017
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Last Update Date | 07/31/2017
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Provider Practice Location Address
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Address Line | 165 W 10TH ST
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-2000
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Country | US
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Telephone | 708-754-3507
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Fax | 708-754-6153
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Provider Business Mailing Address
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Address Line | 3037 CARMEL DR
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City | FLOSSMOOR
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State | IL
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Zip | 60422-2263
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Country | US
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Telephone | 773-983-3948
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARLETHA CAROL HUGHES
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Credential | MD
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Telephone | 708-754-3507
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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 | 036124598
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License Number State | IL
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