MEDICARE: PLASENCIA PEDIATRICS INC

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1356109300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASENCIA PEDIATRICS INC

Provider Business Mailing Address
First Line	:	5939 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1155
Country	:	US
Telephone Number	:	773-637-1600
Fax Number	:	773-637-1520

Provider Business Practice Location Address
First Line	:	5939 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1155
Country	:	US
Telephone Number	:	773-637-1600
Fax Number	:	773-637-1520

Authorized Official
Title or Position	:	CEO
Name	:	VICTOR RAFAEL PLASENCIA
Credential	:	MD
Telephone Number	:	847-691-1407

Provider Enumeration Date	:	03/13/2024
Last Update Date	:	06/18/2025

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