Provider Demographics
NPI:1700898954
Name:CHARM DEVELOPMENT
Entity Type:Organization
Organization Name:CHARM DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-754-8522
Mailing Address - Street 1:403 W LINCOLN HWY
Mailing Address - Street 2:SUITE 25
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2479
Mailing Address - Country:US
Mailing Address - Phone:708-754-8522
Mailing Address - Fax:708-754-8622
Practice Address - Street 1:403 W LINCOLN HWY
Practice Address - Street 2:SUITE 25
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2479
Practice Address - Country:US
Practice Address - Phone:708-754-8522
Practice Address - Fax:708-754-8622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360385802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360385802Medicaid
ILC40957Medicare UPIN
IL442410Medicare ID - Type Unspecified