Provider Demographics
NPI:1215373022
Name:MIDWAY PEDIATRICS LLC
Entity type:Organization
Organization Name:MIDWAY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-582-5200
Mailing Address - Street 1:4254 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4642
Mailing Address - Country:US
Mailing Address - Phone:773-582-5200
Mailing Address - Fax:
Practice Address - Street 1:4254 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4642
Practice Address - Country:US
Practice Address - Phone:773-582-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty