Provider Demographics
NPI:1093747636
Name:DOREENA M MCBRIDE MD PC
Entity Type:Organization
Organization Name:DOREENA M MCBRIDE MD PC
Other - Org Name:PEDICLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOREENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-933-5700
Mailing Address - Street 1:461 BROWN BLVD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2322
Mailing Address - Country:US
Mailing Address - Phone:815-933-5700
Mailing Address - Fax:815-933-8011
Practice Address - Street 1:461 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2322
Practice Address - Country:US
Practice Address - Phone:815-933-5700
Practice Address - Fax:815-933-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0918525OtherCLIA
IL4604555OtherBCBS