Organization
MED PEDS ASSOCIATES
Active
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
Update your record
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