MEDICARE: MATERNAL AND CHILD MEDICAL CARE, S.C

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
2	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1912203209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATERNAL AND CHILD MEDICAL CARE, S.C

Provider Business Mailing Address
First Line	:	2055 WEST ARMY TRAIL ROAD
Second Line	:	SUITE 104
City	:	ADDISON
State	:	IL
Zip	:	60101
Country	:	US
Telephone Number	:	847-650-1452
Fax Number	:	224-535-7260

Provider Business Practice Location Address
First Line	:	2055 W ARMY TRAIL RD
Second Line	:	SUITE 104
City	:	ADDISON
State	:	IL
Zip	:	60101-1478
Country	:	US
Telephone Number	:	847-650-1452
Fax Number	:	224-535-7260

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. ORAWAN SUKAVACHANA
Credential	:	MD
Telephone Number	:	847-650-1452

Provider Enumeration Date	:	02/03/2011
Last Update Date	:	02/03/2011

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