Provider Demographics
NPI:1346424876
Name:SOUTH PARK PEDIATRICS, INC
Entity Type:Organization
Organization Name:SOUTH PARK PEDIATRICS, INC
Other - Org Name:SOUTH PARK PEDIATRICS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-225-0200
Mailing Address - Street 1:15821 SOUTH PARK
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1506
Mailing Address - Country:US
Mailing Address - Phone:708-225-0200
Mailing Address - Fax:708-225-0202
Practice Address - Street 1:15821 SOUTH PARK
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1506
Practice Address - Country:US
Practice Address - Phone:708-225-0200
Practice Address - Fax:708-225-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-168196208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty