Organization
GUSTAVO A. PEDRAZA, M.D., LTD.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GUSTAVO A. PEDRAZA M.D. (PRESIDENT)
(815) 467-4114
Entity
Organization
Contact information
Practice address
25220 S REED ST, CHANNAHON, IL 60410-6000
(815) 467-4114
Mailing address
25220 S REED ST, P.O. BOX 197, CHANNAHON, IL 60410-6000
(815) 467-4114
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
099-00605
BLUE CROSS BLUE SHIELD
IL
Enumeration date
03/28/2008
Last updated
03/28/2008
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