Basic Information
Provider Information | |||||||||
NPI: | 1548337793 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDIATRIC ASSOCIATES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 489 | ||||||||
Address2: |   | ||||||||
City: | MATTESON | ||||||||
State: | IL | ||||||||
PostalCode: | 604430489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087475850 | ||||||||
FaxNumber: | 7087479991 | ||||||||
Practice Location | |||||||||
Address1: | 3749 W 95TH ST | ||||||||
Address2: |   | ||||||||
City: | EVERGREEN PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 608052019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084226569 | ||||||||
FaxNumber: | 7084991511 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 11/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARORA | ||||||||
AuthorizedOfficialFirstName: | SUBASH | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7084226569 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-073878 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 01632846 | 01 | IL | BCBS | OTHER | 036073878 | 05 | IL |   | MEDICAID |