MEDICARE: PEDIATRIC MEDICINE

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	036083477	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437458064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC MEDICINE

Provider Business Mailing Address
First Line	:	902 FLORENCE DR
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-2108
Country	:	US
Telephone Number	:	224-616-9749
Fax Number	:	630-894-3280

Provider Business Practice Location Address
First Line	:	601 W CENTRAL RD
Second Line	:	SUITE 1
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-2379
Country	:	US
Telephone Number	:	847-222-0999
Fax Number	:	847-203-0203

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GISELA GONZALEZ
Credential	:	M.D.
Telephone Number	:	224-616-9749

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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Directions to “PEDIATRIC MEDICINE ” Practice Location

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