Provider Demographics
NPI:1295822120
Name:BLOOMINGDALE GENERAL PEDIATRICS
Entity Type:Organization
Organization Name:BLOOMINGDALE GENERAL PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCUAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-894-3250
Mailing Address - Street 1:109 FAIRFIELD WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1583
Mailing Address - Country:US
Mailing Address - Phone:630-894-3250
Mailing Address - Fax:630-894-3280
Practice Address - Street 1:109 FAIRFIELD WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1583
Practice Address - Country:US
Practice Address - Phone:630-894-3250
Practice Address - Fax:630-894-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083477Medicaid
IL0002201004OtherBCBS
IL036067770Medicaid
IL0002201004OtherBCBS