MEDICARE: CHICAGO PEDIATRIC CLINIC I

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		IL

General Provider Information

NPI Number	:	1366631137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO PEDIATRIC CLINIC I

Provider Business Mailing Address
First Line	:	1916 W IRVING PARK ROAD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613
Country	:	US
Telephone Number	:	773-477-4900
Fax Number	:	773-477-4478

Provider Business Practice Location Address
First Line	:	1916 W IRVING PARK ROAD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613
Country	:	US
Telephone Number	:	773-477-4900
Fax Number	:	773-477-4478

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DARLENE EGUES
Credential	:	MD
Telephone Number	:	773-960-2555

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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