Basic Information
| Provider Information | |||||||||
| NPI: | 1912016783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESCH | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9555 S 52ND AVE | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473189330 | ||||||||
| FaxNumber: | 7088761561 | ||||||||
| Practice Location | |||||||||
| Address1: | 9555 S 52ND AVE | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473189330 | ||||||||
| FaxNumber: | 7088761561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036093057 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0008X | 036093057 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080P0006X | 036-093057 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036093057 | 01 | IL | STATE LICENSE | OTHER | 14D0419824 | 01 | IL | CLIA | OTHER |