Provider Demographics
NPI:1275705394
Name:GUSTAVO A. PEDRAZA, M.D., LTD.
Entity Type:Organization
Organization Name:GUSTAVO A. PEDRAZA, M.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEDRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-467-4114
Mailing Address - Street 1:25220 S REED ST
Mailing Address - Street 2:P.O. BOX 197
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-6000
Mailing Address - Country:US
Mailing Address - Phone:815-467-4114
Mailing Address - Fax:
Practice Address - Street 1:25220 S REED ST
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-6000
Practice Address - Country:US
Practice Address - Phone:815-467-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL099-00605OtherBLUE CROSS BLUE SHIELD
IL982330Medicare UPIN