Provider Demographics
NPI:1598765521
Name:PEDIATRIC SPECIALIST OF THE NW MDSC
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALIST OF THE NW MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-381-5005
Mailing Address - Street 1:5057 SHORELINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1700
Mailing Address - Country:US
Mailing Address - Phone:847-383-1500
Mailing Address - Fax:847-381-5036
Practice Address - Street 1:475 W TERRA COTTA AVE
Practice Address - Street 2:STE 01
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3407
Practice Address - Country:US
Practice Address - Phone:847-381-5005
Practice Address - Fax:847-381-5036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty