Provider Demographics
NPI:1962648386
Name:PROGRESSIVE PEDIATRICS
Entity type:Organization
Organization Name:PROGRESSIVE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AYEZAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-378-1111
Mailing Address - Street 1:215 REMINGTON BLVD
Mailing Address - Street 2:SUITE K
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3656
Mailing Address - Country:US
Mailing Address - Phone:630-378-1111
Mailing Address - Fax:630-378-1112
Practice Address - Street 1:215 REMINGTON BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3656
Practice Address - Country:US
Practice Address - Phone:630-378-1111
Practice Address - Fax:630-378-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112854261QP2300X
IL036089109261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG10316Medicare UPIN
IL164966Medicare UPIN