Provider Demographics
NPI:1316597164
Name:PM PEDIATRICS OF ILLINOIS
Entity type:Organization
Organization Name:PM PEDIATRICS OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-207-7936
Mailing Address - Street 1:1 HOLLOW LN STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1215
Mailing Address - Country:US
Mailing Address - Phone:516-869-0650
Mailing Address - Fax:516-869-0655
Practice Address - Street 1:2835 SHOWPLACE DR STE 119
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5056
Practice Address - Country:US
Practice Address - Phone:630-470-4878
Practice Address - Fax:630-870-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-13
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty