MEDICARE: FGM PEDIATRICS 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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001623614	OTHER	IL	BC BS OF IL

General Provider Information

NPI Number	:	1780633313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FGM PEDIATRICS SC

Provider Business Mailing Address
First Line	:	PO BOX 967
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-0967
Country	:	US
Telephone Number	:	708-532-6029
Fax Number	:	708-532-6095

Provider Business Practice Location Address
First Line	:	8711 W CERMAK RD
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1166
Country	:	US
Telephone Number	:	708-442-7979
Fax Number	:	708-442-8574

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MARC A FREED
Credential	:	DO
Telephone Number	:	708-442-7979

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	05/02/2018

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