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General NPI Number Information
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NPI Number | 1922435890
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Entity Type | Organization
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Legal Business Name | PEDIATRIC URGENT CARE OF ILLINOIS, LLC
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Dates
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Enumeration Date | 10/08/2013
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Last Update Date | 10/08/2013
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Provider Practice Location Address
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Address Line | 215 REMINGTON BLVD SUITE K
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City | BOLINGBROOK
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State | IL
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Zip | 60440-3656
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Country | US
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Telephone | 630-487-1556
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Fax |
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Provider Business Mailing Address
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Address Line | 5611 COLLEYVILLE BLVD STE 100
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City | COLLEYVILLE
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State | TX
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Zip | 76034-6069
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Country | US
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Telephone | 817-485-6000
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Fax | 214-276-1472
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Authorized Official
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Title or Position | OWNER
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Name | MR. GERARDO REYES
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Credential | M.D.
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Telephone | 630-487-1556
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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 | 036091219
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License Number State | IL
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