Provider Demographics
NPI:1407032022
Name:CHICAGOLAND COMMUNITY PEDIATRIC CARDIOLOGY SC
Entity type:Organization
Organization Name:CHICAGOLAND COMMUNITY PEDIATRIC CARDIOLOGY SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-217-7799
Mailing Address - Street 1:2923 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4677
Mailing Address - Country:US
Mailing Address - Phone:312-951-5800
Mailing Address - Fax:312-951-5816
Practice Address - Street 1:2923 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4677
Practice Address - Country:US
Practice Address - Phone:312-951-5800
Practice Address - Fax:312-951-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007521261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072228Medicaid
IL036100179Medicaid
IL042007521OtherSTATE LICENSE