Provider Demographics
NPI:1962483669
Name:MIDWEST PEDIATRIC CARDIOLOGY, P.C.
Entity Type:Organization
Organization Name:MIDWEST PEDIATRIC CARDIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-684-5580
Mailing Address - Street 1:621 PLAINFIELD RD
Mailing Address - Street 2:#105
Mailing Address - City:WILLOW BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5343
Mailing Address - Country:US
Mailing Address - Phone:630-321-9811
Mailing Address - Fax:630-321-9813
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5580
Practice Address - Fax:708-684-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1617609OtherBCBS OF ILLINOIS
IL776420Medicare ID - Type Unspecified