Provider Demographics
NPI:1013190727
Name:MARIA RIZA BAUTISTA MD SC
Entity Type:Organization
Organization Name:MARIA RIZA BAUTISTA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA RIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-487-5224
Mailing Address - Street 1:326 W 64TH ST
Mailing Address - Street 2:SUITE # 302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3114
Mailing Address - Country:US
Mailing Address - Phone:773-487-5224
Mailing Address - Fax:
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:SUITE # 302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-487-5224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216095Medicare PIN