Provider Demographics
NPI:1073053443
Name:COMMUNITY PEDIATRICS
Entity Type:Organization
Organization Name:COMMUNITY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:H
Authorized Official - Last Name:BHASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-1600
Mailing Address - Street 1:16001 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-0500
Mailing Address - Country:US
Mailing Address - Phone:815-744-1600
Mailing Address - Fax:815-838-0556
Practice Address - Street 1:16001 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0500
Practice Address - Country:US
Practice Address - Phone:815-744-1600
Practice Address - Fax:815-838-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093909208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10700025Medicaid