Provider Demographics
NPI:1114111028
Name:WILLIAM, BOB (MD)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:WILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16519 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-2606
Mailing Address - Country:US
Mailing Address - Phone:630-646-5020
Mailing Address - Fax:630-646-5025
Practice Address - Street 1:16519 S RTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-2606
Practice Address - Country:US
Practice Address - Phone:630-646-5020
Practice Address - Fax:630-646-5025
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361244752Medicaid
IL9933040OtherBCBS
IL0361244752Medicaid