Provider Demographics
NPI:1710110473
Name:FOX RIVER PEDIATRICS SC
Entity Type:Organization
Organization Name:FOX RIVER PEDIATRICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYEZAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-926-4471
Mailing Address - Street 1:11000 US HIGHWAY 34
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545-9824
Mailing Address - Country:US
Mailing Address - Phone:630-552-9852
Mailing Address - Fax:630-552-9857
Practice Address - Street 1:11000 US HIGHWAY 34
Practice Address - Street 2:SUITE 3
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-9824
Practice Address - Country:US
Practice Address - Phone:630-552-9852
Practice Address - Fax:630-552-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112854208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty