Provider Demographics
NPI:1184679979
Name:EBS PEDIATRICS
Entity Type:Organization
Organization Name:EBS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-429-1600
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:708-532-6095
Practice Address - Street 1:6720 167TH ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2872
Practice Address - Country:US
Practice Address - Phone:708-429-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633131OtherBCBS PROVIDER #
IL0001633131OtherBCBS PROVIDER #