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General NPI Number Information
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NPI Number | 1366631137
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Entity Type | Organization
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Legal Business Name | CHICAGO PEDIATRIC CLINIC I
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 10/17/2007
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Provider Practice Location Address
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Address Line | 1916 W IRVING PARK ROAD
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City | CHICAGO
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State | IL
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Zip | 60613
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Country | US
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Telephone | 773-477-4900
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Fax | 773-477-4478
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Provider Business Mailing Address
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Address Line | 1916 W IRVING PARK ROAD
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City | CHICAGO
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State | IL
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Zip | 60613
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Country | US
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Telephone | 773-477-4900
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Fax | 773-477-4478
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Authorized Official
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Title or Position | PRESIDENT
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Name | DARLENE EGUES
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Credential | MD
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Telephone | 773-960-2555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | IL
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