Organization
PEDIATRIC CLINIC LTD.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARIA STAISZ M.D. (PRESIDENT)
(773) 725-5400
Entity
Organization
Contact information
Practice address
6416 W BELMONT AVE, CHICAGO, IL 60634-3921
(773) 725-5400
(773) 725-4704
Mailing address
6416 W BELMONT AVE, CHICAGO, IL 60634-3921
(773) 725-5400
(773) 725-4704
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0021609992
BLUECROSSBLUESHIELD
IL
01
—
1614
MCNP BLUECHOICE
ID
01
—
2269939
CIGNA
IL
01
—
8581
MCNP BLUECHOICE
IL
Enumeration date
11/07/2006
Last updated
08/22/2020
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