Provider Demographics
NPI:1376732784
Name:OBSTETRICS & GYNECOLOGY PC
Entity Type:Organization
Organization Name:OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-440-1600
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 830
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-440-1600
Mailing Address - Fax:312-440-3508
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE 830
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-440-1600
Practice Address - Fax:312-440-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060003474207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01617247OtherBLUE CROSS BLUE SHIELD