1619193760 NPI number — JOLIET PEDIATRICS AND FAMILY CARE INC

Table of content: (NPI 1619193760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619193760 NPI number — JOLIET PEDIATRICS AND FAMILY CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOLIET PEDIATRICS AND FAMILY CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619193760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1721 GLENWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-5835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-741-8888
Provider Business Mailing Address Fax Number:
815-730-3323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 N LARKIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-3460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-741-8888
Provider Business Practice Location Address Fax Number:
815-730-3323
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NIAZI
Authorized Official First Name:
SHERAHSAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-741-8888

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 036089109 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036089109 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com