NPIMap

Organization Active NPI

Med Peds Associates

  • Non-Pharmacy Dispensing Site
  • Kankakee, IL
National Provider Identifier
1649353970
Registry record updated Sep 3, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Non-Pharmacy Dispensing SiteTaxonomy code 332900000X
License
036074737 Issued in IL
Legal business name
MED PEDS ASSOCIATES
Doing business as
Med Peds Associates
Practice address
375 N Wall St Ste P520
Kankakee, IL 60901-3493
Phone
(815) 933-0194
Fax
(815) 933-1444
NPI assigned
Oct 23, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 3, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Direndia Shackelford
Title
Managed Care Specialist
Phone
(800) 654-0889

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Pharmacy Dispensing Site 332900000X 036074737 IL Primary

Addresses

Primary practice location

375 N Wall St Ste P520
Kankakee, IL 60901-3493

Mailing address

375 N Wall St Ste P520
Kankakee, IL 60901-3493

Other identifiers 2

IdentifierTypeStateIssuer
1472505OtherOTHER ID NUMBER-COMMERCIAL NUMBER
036074737MedicaidIL

Other names 1

  • MED PEDS ASSOCIATES Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Med Peds Associates2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161561600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1220400000000",
    "number": "1649353970",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "375 N WALL ST STE P520",
            "city": "KANKAKEE",
            "state": "IL",
            "postal_code": "609013493"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "375 N WALL ST STE P520",
            "city": "KANKAKEE",
            "state": "IL",
            "postal_code": "609013493",
            "telephone_number": "815-933-0194",
            "fax_number": "815-933-1444"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MED PEDS ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-23",
        "last_updated": "2008-09-03",
        "status": "A",
        "authorized_official_last_name": "SHACKELFORD",
        "authorized_official_first_name": "DIRENDIA",
        "authorized_official_title_or_position": "MANAGED CARE SPECIALIST",
        "authorized_official_telephone_number": "800-654-0889"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "IL",
            "license": "036074737",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "1472505",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036074737",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MED PEDS ASSOCIATES",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kankakee, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.