Provider Demographics
NPI:1922435890
Name:PEDIATRIC URGENT CARE OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:PEDIATRIC URGENT CARE OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-487-1556
Mailing Address - Street 1:5611 COLLEYVILLE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6069
Mailing Address - Country:US
Mailing Address - Phone:817-485-6000
Mailing Address - Fax:214-276-1472
Practice Address - Street 1:215 REMINGTON BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3656
Practice Address - Country:US
Practice Address - Phone:630-487-1556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091219208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty