Provider Demographics
NPI:1356507834
Name:WOODRIDGECLINIC S.C
Entity Type:Organization
Organization Name:WOODRIDGECLINIC S.C
Other - Org Name:LILAC PARK MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PARAGI
Authorized Official - Middle Name:U
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-324-4677
Mailing Address - Street 1:7530 WOODWARD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3100
Mailing Address - Country:US
Mailing Address - Phone:630-910-1177
Mailing Address - Fax:
Practice Address - Street 1:805 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3300
Practice Address - Country:US
Practice Address - Phone:630-620-6225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODRIDGECLINIC S.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-04
Last Update Date:2023-10-20
Deactivation Date:2023-09-05
Deactivation Code:
Reactivation Date:2023-10-20
Provider Licenses
StateLicense IDTaxonomies
IL042-0060088207RA0000X, 2080A0000X
IL042-006088208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherEIN NUMBER
IL=========OtherEIN NUMBER