Basic Information
| Provider Information | |||||||||
| NPI: | 1265440663 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRICS AND CHILD DEVELOPMENT CLINIC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2575 W ALGONQUIN RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALGONQUIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601029403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476584574 | ||||||||
| FaxNumber: | 8475876113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2575 W ALGONQUIN RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALGONQUIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601029403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476584574 | ||||||||
| FaxNumber: | 8475876113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ARSHAD | ||||||||
| AuthorizedOfficialFirstName: | MUSSARAT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8476584574 | ||||||||
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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 | 2080P0008X | 036092453 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080P0006X | 036092453 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036092453 | 05 | IL | MEDICAID | 05628082 | 01 | IL | BLUE CROSS/SHIELD | OTHER |