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General NPI Number Information
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NPI Number | 1558445122
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Entity Type | Organization
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Legal Business Name | BOULEVARD PEDIATRICS SC
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 30 E 15TH STREET SUITE 205
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411
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Country | US
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Telephone | 708-755-4401
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Fax | 708-755-4479
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Provider Business Mailing Address
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Address Line | 30 E 15TH STREET SUITE 205
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411
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Country | US
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Telephone | 708-755-4401
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Fax | 708-755-4479
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Authorized Official
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Title or Position | OWNER
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Name | ANTONIO MARRA
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Credential | MD
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Telephone | 708-755-4401
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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 |
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License Number State | IL
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