Provider Demographics
NPI:1336294800
Name:MUNDELEIN PEDIATRICS, S.C.
Entity Type:Organization
Organization Name:MUNDELEIN PEDIATRICS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-548-7337
Mailing Address - Street 1:1170 E BELVIDERE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2061
Mailing Address - Country:US
Mailing Address - Phone:847-548-7337
Mailing Address - Fax:847-548-9909
Practice Address - Street 1:1170 E BELVIDERE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2061
Practice Address - Country:US
Practice Address - Phone:847-548-7337
Practice Address - Fax:847-548-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty