Basic Information
| Provider Information | |||||||||
| NPI: | 1902903610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP OF ILLINOIS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 CONCORD TER | ||||||||
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| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8446862961 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154894177 | ||||||||
| FaxNumber: | 8154905906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | POOLE | ||||||||
| AuthorizedOfficialFirstName: | ARNOLD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SIGNING AUTHORITY | ||||||||
| AuthorizedOfficialTelephone: | 9543840175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.