1780633313 NPI number — FGM PEDIATRICS SC

Table of content: (NPI 1780633313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780633313 NPI number — FGM PEDIATRICS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FGM PEDIATRICS SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780633313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 967
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-0967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-532-6029
Provider Business Mailing Address Fax Number:
708-532-6095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8711 W CERMAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH RIVERSIDE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60546-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-442-7979
Provider Business Practice Location Address Fax Number:
708-442-8574
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREED
Authorized Official First Name:
MARC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
708-442-7979

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001623614 . This is a "BC BS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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