Provider Demographics
NPI:1083674048
Name:PONGRACIC, JACQUELINE ANN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:PONGRACIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:#60 CHILDRENS MEMORIAL HOSPITAL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-227-6011
Mailing Address - Fax:312-227-9401
Practice Address - Street 1:2515 N CLARK ST
Practice Address - Street 2:CHILDRENS MEMORIAL HOSPITAL OUTPATIENT CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:312-227-6010
Practice Address - Fax:312-227-9401
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360830102080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083010Medicaid
E56819Medicare UPIN
IL036083010Medicaid