Provider Demographics
NPI:1912295494
Name:GENESIS PEDIATRIC MEDICINE, LLC
Entity Type:Organization
Organization Name:GENESIS PEDIATRIC MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:REGNIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-899-0001
Mailing Address - Street 1:1830 MEDITERRANEAN DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3144
Mailing Address - Country:US
Mailing Address - Phone:815-899-0001
Mailing Address - Fax:815-899-0002
Practice Address - Street 1:1830 MEDITERRANEAN DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3144
Practice Address - Country:US
Practice Address - Phone:815-899-0001
Practice Address - Fax:815-899-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097453Medicaid