Organization
MED PEDS ASSOCIATES
Active
Other names
MED PEDS ASSOCIATES
Organization subpart
No
Provider details
NPI number
Authorized official
DIRENDIA SHACKELFORD (MANAGED CARE SPECIALIST)
(800) 654-0889
Entity
Organization
Contact information
Practice address
375 N WALL ST STE P520, KANKAKEE, IL 60901-3493
(815) 933-0194
(815) 933-1444
Mailing address
375 N WALL ST STE P520, KANKAKEE, IL 60901-3493
Taxonomy
Speciality
Code
Description
License number
State
332900000X
Non-Pharmacy Dispensing Site
Primary
036074737
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036074737
—
IL
01
—
1472505
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
10/23/2006
Last updated
09/03/2008
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