Basic Information
| Provider Information | |||||||||
| NPI: | 1780633313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FGM PEDIATRICS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085326029 | ||||||||
| FaxNumber: | 7085326095 | ||||||||
| Practice Location | |||||||||
| Address1: | 8711 W CERMAK RD | ||||||||
| Address2: | |||||||||
| City: | NORTH RIVERSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605461166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084427979 | ||||||||
| FaxNumber: | 7084428574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | FREED | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7084427979 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0001623614 | 01 | IL | BC BS OF IL | OTHER |