Provider Demographics
NPI:1346764438
Name:SUBURBAN PEDIATRICS MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:SUBURBAN PEDIATRICS MEDICAL CENTER, LLC
Other - Org Name:DR. CARLETHA HUGHES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLETHA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-754-3507
Mailing Address - Street 1:3037 CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2263
Mailing Address - Country:US
Mailing Address - Phone:773-983-3948
Mailing Address - Fax:
Practice Address - Street 1:165 W 10TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2000
Practice Address - Country:US
Practice Address - Phone:708-754-3507
Practice Address - Fax:708-754-6153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1023249075Medicaid