Provider Demographics
NPI:1578612438
Name:CHILDRENS MEDICAL CENTER SC
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NADA
Authorized Official - Middle Name:AL
Authorized Official - Last Name:DALLAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-847-9004
Mailing Address - Street 1:1801 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-3872
Mailing Address - Country:US
Mailing Address - Phone:773-847-9004
Mailing Address - Fax:773-847-9008
Practice Address - Street 1:1801 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3872
Practice Address - Country:US
Practice Address - Phone:773-847-9004
Practice Address - Fax:773-847-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RS0012X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Not Answered2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001636919OtherBLUE CROSS BLUE SHIELD
=========OtherEMPLOYER IDENTIFICATION N