Provider Demographics
NPI:1629641477
Name:MED-PED MEDICAL CENTER SC
Entity Type:Organization
Organization Name:MED-PED MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:PLASENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-637-1600
Mailing Address - Street 1:5939 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1155
Mailing Address - Country:US
Mailing Address - Phone:773-637-1600
Mailing Address - Fax:773-637-1520
Practice Address - Street 1:5939 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1155
Practice Address - Country:US
Practice Address - Phone:773-637-1600
Practice Address - Fax:773-637-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty