Provider Demographics
NPI:1316952765
Name:SUBURBAN PEDIATRICS, LTD.
Entity type:Organization
Organization Name:SUBURBAN PEDIATRICS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-296-1177
Mailing Address - Street 1:9000 WAUKEGAN RD STE 240
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2128
Mailing Address - Country:US
Mailing Address - Phone:847-296-1177
Mailing Address - Fax:847-296-6435
Practice Address - Street 1:9000 WAUKEGAN RD STE 240
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2128
Practice Address - Country:US
Practice Address - Phone:847-296-1177
Practice Address - Fax:847-296-6437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-000280208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty