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General NPI Number Information
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NPI Number | 1912295494
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Entity Type | Organization
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Legal Business Name | GENESIS PEDIATRIC MEDICINE, LLC
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Dates
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Enumeration Date | 07/18/2011
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Last Update Date | 07/18/2011
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Provider Practice Location Address
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Address Line | 1830 MEDITERRANEAN DR
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City | SYCAMORE
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State | IL
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Zip | 60178-3144
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Country | US
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Telephone | 815-899-0001
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Fax | 815-899-0002
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Provider Business Mailing Address
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Address Line | 1830 MEDITERRANEAN DR
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City | SYCAMORE
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State | IL
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Zip | 60178-3144
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Country | US
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Telephone | 815-899-0001
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Fax | 815-899-0002
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK ALAN REGNIER
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Credential | M.D.
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Telephone | 815-899-0001
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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 | 036097453
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License Number State | IL
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