MEDICARE: PEDIATRIC CLINIC LTD.

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	174400000X	Specialist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0021609992	OTHER	IL	BLUECROSSBLUESHIELD
2	1614	OTHER	ID	MCNP BLUECHOICE
3	8581	OTHER	IL	MCNP BLUECHOICE
4	2269939	OTHER	IL	CIGNA

General Provider Information

NPI Number	:	1568531903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CLINIC LTD.

Provider Business Mailing Address
First Line	:	6416 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3921
Country	:	US
Telephone Number	:	773-725-5400
Fax Number	:	773-725-4704

Provider Business Practice Location Address
First Line	:	6416 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3921
Country	:	US
Telephone Number	:	773-725-5400
Fax Number	:	773-725-4704

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIA STAISZ
Credential	:	M.D.
Telephone Number	:	773-725-5400

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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Directions to “PEDIATRIC CLINIC LTD. ” Practice Location

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