Provider Demographics
NPI:1205310356
Name:BACK TO BASICS PEDIATRICS SC
Entity type:Organization
Organization Name:BACK TO BASICS PEDIATRICS SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-520-0087
Mailing Address - Street 1:2403 HARNISH DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6803
Mailing Address - Country:US
Mailing Address - Phone:224-333-0730
Mailing Address - Fax:224-333-0748
Practice Address - Street 1:2403 HARNISH DR STE 101
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6803
Practice Address - Country:US
Practice Address - Phone:224-520-0087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty