Provider Demographics
NPI:1801120860
Name:GRACE PEDIATRICS LLC
Entity type:Organization
Organization Name:GRACE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ARJUMAND
Authorized Official - Middle Name:
Authorized Official - Last Name:FARHANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-933-8446
Mailing Address - Street 1:PO BOX 5005
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-5005
Mailing Address - Country:US
Mailing Address - Phone:630-784-8600
Mailing Address - Fax:630-456-4086
Practice Address - Street 1:1118 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3498
Practice Address - Country:US
Practice Address - Phone:630-784-8600
Practice Address - Fax:630-456-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106640261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36106640Medicaid