Provider Demographics
NPI:1346230232
Name:TINLEY PARK PEDIATRIC ASSOCIATES SC
Entity type:Organization
Organization Name:TINLEY PARK PEDIATRIC ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-342-7032
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0789
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6703 159TH ST
Practice Address - Street 2:SUITE 115
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1781
Practice Address - Country:US
Practice Address - Phone:708-342-7032
Practice Address - Fax:708-342-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1634171OtherBCBSIL GROUP NUMBER
IL209313Medicare PIN