Provider Demographics
NPI:1609216084
Name:CHICAGO METROPOLITAN OBSTETRICIANS GYNECOLOGISTS AND PEDIATRICIANS
Entity Type:Organization
Organization Name:CHICAGO METROPOLITAN OBSTETRICIANS GYNECOLOGISTS AND PEDIATRICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-333-3030
Mailing Address - Street 1:PO BOX 4685
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-4685
Mailing Address - Country:US
Mailing Address - Phone:708-333-3030
Mailing Address - Fax:708-333-7453
Practice Address - Street 1:15620 SOUTH WOOD STREET
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4171
Practice Address - Country:US
Practice Address - Phone:708-333-3030
Practice Address - Fax:708-333-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043976207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036043976Medicaid