Basic Information
Provider Information | |||||||||
NPI: | 1780724898 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHICAGO PEDIATRIC CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 777 OAKMONT LN | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | WESTMONT | ||||||||
State: | IL | ||||||||
PostalCode: | 605595511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307892550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1918 W IRVING PARK RD | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606132408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7734774900 | ||||||||
FaxNumber: | 7734774478 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EGUES | ||||||||
AuthorizedOfficialFirstName: | DARLENE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7734774900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 201026 | 01 | IL | ADVOCATE HLTH PRTNRS ID | OTHER | 01632128 | 01 | IL | BCBS PROVIDER ID | OTHER |