Provider Demographics
NPI:1255305157
Name:CARLOS F PEDRERA MD SC
Entity Type:Organization
Organization Name:CARLOS F PEDRERA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:PEDRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD SC
Authorized Official - Phone:773-278-2600
Mailing Address - Street 1:6545 N LONGMEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3205
Mailing Address - Country:US
Mailing Address - Phone:847-677-7996
Mailing Address - Fax:847-673-4032
Practice Address - Street 1:1431 N WESTERN AVE STE 502
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1774
Practice Address - Country:US
Practice Address - Phone:773-278-2600
Practice Address - Fax:773-278-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051754Medicaid
628340Medicare ID - Type Unspecified
C44229Medicare UPIN