Provider Demographics
NPI:1306198247
Name:CERMAK CHILDREN'S CLINIC, S.C.
Entity type:Organization
Organization Name:CERMAK CHILDREN'S CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:AMPALLOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-840-9714
Mailing Address - Street 1:1044 N MOZART ST
Mailing Address - Street 2:STE - 402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2789
Mailing Address - Country:US
Mailing Address - Phone:773-292-4501
Mailing Address - Fax:773-292-2613
Practice Address - Street 1:6917 W CERMAK ROAD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60804-2172
Practice Address - Country:US
Practice Address - Phone:708-788-4933
Practice Address - Fax:708-788-5296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105483Medicaid