MEDICARE: DELAVAN PEDIATRICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	036112406	IL

General Provider Information

NPI Number	:	1053675181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAVAN PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	101 E 5TH ST
Second Line	:
City	:	DELAVAN
State	:	IL
Zip	:	61734-9619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 E 5TH ST
Second Line	:
City	:	DELAVAN
State	:	IL
Zip	:	61734-9619
Country	:	US
Telephone Number	:	309-244-8445
Fax Number	:	309-244-8452

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	JOSEPH FLINT
Credential	:	MD
Telephone Number	:	309-244-8445

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	07/03/2012

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