Provider Demographics
NPI:1235373853
Name:EVELYN G. BASCO,M.D.,S.C.
Entity Type:Organization
Organization Name:EVELYN G. BASCO,M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:GANADEN
Authorized Official - Last Name:BASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-533-3440
Mailing Address - Street 1:3900 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2354
Mailing Address - Country:US
Mailing Address - Phone:773-533-3440
Mailing Address - Fax:
Practice Address - Street 1:3900 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2354
Practice Address - Country:US
Practice Address - Phone:773-533-3440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055675261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055675Medicaid
ILD13176Medicare UPIN