Organization
NORTHSIDE-SUBURBAN PEDIATRIC ASSOCIATES, S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY DEUTSCH (ADMINISTRATOR/MANAGER)
(773) 777-5437
Entity
Organization
Contact information
Practice address
4801 W PETERSON AVE, STE 506, CHICAGO, IL 60646-5795
(773) 777-5437
(773) 777-7567
Mailing address
4801 W PETERSON AVE, STE 506, CHICAGO, IL 60646-5795
(773) 777-5437
(773) 777-7567
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01615555
BLUE SHIELD PROVIDER #
IL
Enumeration date
06/24/2005
Last updated
08/22/2020
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