Provider Demographics
NPI:1558445122
Name:BOULEVARD PEDIATRICS SC
Entity Type:Organization
Organization Name:BOULEVARD PEDIATRICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-755-4401
Mailing Address - Street 1:30 E 15TH STREET
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411
Mailing Address - Country:US
Mailing Address - Phone:708-755-4401
Mailing Address - Fax:708-755-4479
Practice Address - Street 1:30 E 15TH STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-755-4401
Practice Address - Fax:708-755-4479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty