Provider Demographics
NPI:1730201922
Name:ABC PEDIATRICS, LTD.
Entity type:Organization
Organization Name:ABC PEDIATRICS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROUSONELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-355-0003
Mailing Address - Street 1:1331 W 75TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540
Mailing Address - Country:US
Mailing Address - Phone:630-355-0003
Mailing Address - Fax:630-355-9822
Practice Address - Street 1:1331 W 75TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540
Practice Address - Country:US
Practice Address - Phone:630-355-0003
Practice Address - Fax:630-355-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618674208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0866815OtherCLIA WAIVER CERT
IL042.618674OtherREGISTERED MEDICAL CORP
IL02201648OtherBC BS PROVIDER NUMBER