Provider Demographics
NPI:1154476638
Name:EDELSON PEDIATRICS SC
Entity Type:Organization
Organization Name:EDELSON PEDIATRICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:FREDERIC
Authorized Official - Last Name:EDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-588-3889
Mailing Address - Street 1:15750 S BELL RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8420
Mailing Address - Country:US
Mailing Address - Phone:708-301-6004
Mailing Address - Fax:
Practice Address - Street 1:15750 S BELL RD STE 2A
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8420
Practice Address - Country:US
Practice Address - Phone:708-301-6004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG19148Medicaid