Basic Information
| Provider Information | |||||||||
| NPI: | 1366631137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICAGO PEDIATRIC CLINIC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1916 W IRVING PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734774900 | ||||||||
| FaxNumber: | 7734774478 | ||||||||
| Practice Location | |||||||||
| Address1: | 1916 W IRVING PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734774900 | ||||||||
| FaxNumber: | 7734774478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | EGUES | ||||||||
| AuthorizedOfficialFirstName: | DARLENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7739602555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.