=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386187458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A2Z CARE MED-PEDS SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2016
-----------------------------------------------------
Last Update Date | 04/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 EAST BOUGTON ROAD SUITE 110
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-2194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-755-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3250 LACEY RD SUITE 160
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-712-4010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE MANAGEMENT CONSULTANT
-----------------------------------------------------
Name | MRS. GRACE HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-712-4010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | 036114636
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------