Provider Demographics
NPI:1902802770
Name:NORTHSIDE-SUBURBAN PEDIATRIC ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:NORTHSIDE-SUBURBAN PEDIATRIC ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-777-5437
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:STE 506
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5795
Mailing Address - Country:US
Mailing Address - Phone:773-777-5437
Mailing Address - Fax:773-777-7567
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:STE 506
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5795
Practice Address - Country:US
Practice Address - Phone:773-777-5437
Practice Address - Fax:773-777-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615555OtherBLUE SHIELD PROVIDER #