Provider Demographics
NPI:1366631137
Name:CHICAGO PEDIATRIC CLINIC I
Entity Type:Organization
Organization Name:CHICAGO PEDIATRIC CLINIC I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EGUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-960-2555
Mailing Address - Street 1:1916 W IRVING PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-477-4900
Mailing Address - Fax:773-477-4478
Practice Address - Street 1:1916 W IRVING PARK ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-477-4900
Practice Address - Fax:773-477-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center