Organization
GUSTAVO A . PEDRAZA M.D., LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GUSTAVO A PEDRAZA M.D. (PRESIDENT)
(815) 467-4114
Entity
Organization
Contact information
Practice address
23952 S NORTHERN ILLINOIS DR, CHANNAHON, IL 60410-5184
(815) 467-4114
(815) 467-1774
Mailing address
23952 S NORTHERN ILLINOIS DR, P.O. BOX 197, CHANNAHON, IL 60410-5184
(815) 467-4114
(815) 467-1774
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
036076520
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
982330
MEDICARE I.D. NUMBER
IL
Enumeration date
02/09/2010
Last updated
02/09/2010
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