Provider Demographics
NPI:1407973183
Name:PICKERING, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PICKERING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:180 HARVESTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5993
Mailing Address - Country:US
Mailing Address - Phone:773-834-1061
Mailing Address - Fax:773-834-0946
Practice Address - Street 1:1111 E 87TH ST
Practice Address - Street 2:SUITE 900
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-7038
Practice Address - Country:US
Practice Address - Phone:773-702-2900
Practice Address - Fax:773-702-2277
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036102715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102715Medicaid
ILK18711Medicare PIN
ILH29997Medicare UPIN