Provider Demographics
NPI:1568630234
Name:COMPREHENSIVE PEDIATRIC CARE
Entity Type:Organization
Organization Name:COMPREHENSIVE PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:
Authorized Official - First Name:MARIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-404-6000
Mailing Address - Street 1:657 E. GOLF RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-4968
Mailing Address - Country:US
Mailing Address - Phone:224-404-6000
Mailing Address - Fax:773-774-0019
Practice Address - Street 1:657 E. GOLF RD
Practice Address - Street 2:SUITE 309
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4968
Practice Address - Country:US
Practice Address - Phone:224-404-6000
Practice Address - Fax:773-774-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118003208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118003Medicaid