Provider Demographics
NPI:1275726564
Name:DESTEFANO&STAMAT PEDIATRICS
Entity Type:Organization
Organization Name:DESTEFANO&STAMAT PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-923-6262
Mailing Address - Street 1:7550 W COLLEGE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1026
Mailing Address - Country:US
Mailing Address - Phone:708-923-6262
Mailing Address - Fax:708-923-6868
Practice Address - Street 1:7550 W COLLEGE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1026
Practice Address - Country:US
Practice Address - Phone:708-923-6262
Practice Address - Fax:708-923-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069672Medicaid
IL036069672Medicaid