MEDICARE: MED-PED MEDICAL CENTER SC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1629641477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED-PED MEDICAL CENTER SC

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	:	OWNER
Name	:	DR. WALTER PLASENCIA
Credential	:	MD
Telephone Number	:	773-637-1600

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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Directions to “MED-PED MEDICAL CENTER SC ” Practice Location

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