Basic Information
| Provider Information | |||||||||
| NPI: | 1073025045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLE HEALTH MAMA PEDIATRICS, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 379 | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604620379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084609833 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Practice Location | |||||||||
| Address1: | 13740 ELM ST | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604621510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084609833 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOZDEN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3122188748 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036116141 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.