Provider Demographics
NPI:1790950244
Name:KIDS PLACE OF WILLOWBROOL SC
Entity Type:Organization
Organization Name:KIDS PLACE OF WILLOWBROOL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILOBOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-323-7337
Mailing Address - Street 1:6727 KINGERY HWY
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5142
Mailing Address - Country:US
Mailing Address - Phone:630-323-7337
Mailing Address - Fax:
Practice Address - Street 1:6727 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5142
Practice Address - Country:US
Practice Address - Phone:630-323-7337
Practice Address - Fax:815-463-8946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360875522080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087552Medicaid
ILG20964Medicare UPIN