Provider Demographics
NPI:1356475495
Name:DARRYL M. BRONSON, M.D., S.C.
Entity Type:Organization
Organization Name:DARRYL M. BRONSON, M.D., S.C.
Other - Org Name:DARRYL M. BRONSON, MD, BONNIE L. BARSKY, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRONSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-432-4650
Mailing Address - Street 1:767 PARK AVE W
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2400
Mailing Address - Country:US
Mailing Address - Phone:847-432-4650
Mailing Address - Fax:
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 310
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-432-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055481174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty