Provider Demographics
NPI:1780724898
Name:CHICAGO PEDIATRIC CLINIC
Entity type:Organization
Organization Name:CHICAGO PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EGUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-477-4900
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-789-2550
Mailing Address - Fax:
Practice Address - Street 1:1918 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2408
Practice Address - Country:US
Practice Address - Phone:773-477-4900
Practice Address - Fax:773-477-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201026OtherADVOCATE HLTH PRTNRS ID
IL01632128OtherBCBS PROVIDER ID
IL=========01OtherADVOCATE HLTH CTRS ID