Provider Demographics
NPI:1740532126
Name:PRENDERGAST PEDIATRICS P.C.
Entity type:Organization
Organization Name:PRENDERGAST PEDIATRICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHAJA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PRENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:MS OTR/L
Authorized Official - Phone:810-656-2863
Mailing Address - Street 1:547 W SURF ST
Mailing Address - Street 2:UNIT 4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6034
Mailing Address - Country:US
Mailing Address - Phone:810-656-2863
Mailing Address - Fax:
Practice Address - Street 1:547 W SURF ST
Practice Address - Street 2:UNIT 4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6034
Practice Address - Country:US
Practice Address - Phone:810-656-2863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-008197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty