Basic Information
| Provider Information | |||||||||
| NPI: | 1083674048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONGRACIC | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHILDRENS PLAZA | ||||||||
| Address2: | #60 CHILDRENS MEMORIAL HOSPITAL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122276011 | ||||||||
| FaxNumber: | 3122279401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2515 N CLARK ST | ||||||||
| Address2: | CHILDRENS MEMORIAL HOSPITAL OUTPATIENT CENTER | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122276010 | ||||||||
| FaxNumber: | 3122279401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X | 036083010 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 036083010 | 05 | IL | MEDICAID |