Provider Demographics
NPI:1265946982
Name:PEDIATRIC PRACTICE ALLIANCE LLC
Entity type:Organization
Organization Name:PEDIATRIC PRACTICE ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMPRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAWLANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-235-5000
Mailing Address - Street 1:7110 W 127TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1571
Mailing Address - Country:US
Mailing Address - Phone:630-235-5000
Mailing Address - Fax:
Practice Address - Street 1:7110 W 127TH ST
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1571
Practice Address - Country:US
Practice Address - Phone:630-235-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057974Medicaid