Provider Demographics
NPI:1043535248
Name:KID CARE DOCTORS
Entity type:Organization
Organization Name:KID CARE DOCTORS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-274-0498
Mailing Address - Street 1:2254 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2411
Mailing Address - Country:US
Mailing Address - Phone:773-222-9170
Mailing Address - Fax:708-222-9173
Practice Address - Street 1:2240 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2411
Practice Address - Country:US
Practice Address - Phone:708-222-9170
Practice Address - Fax:708-222-9173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KID CARE PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherSTATE OF ILLINOIS