Provider Demographics
NPI:1417149972
Name:BUN SIU L CO, MD, SC
Entity Type:Organization
Organization Name:BUN SIU L CO, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-838-7965
Mailing Address - Street 1:300 READ ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3265
Mailing Address - Country:US
Mailing Address - Phone:815-838-7965
Mailing Address - Fax:815-838-8011
Practice Address - Street 1:300 READ ST
Practice Address - Street 2:SUITE C
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3265
Practice Address - Country:US
Practice Address - Phone:815-838-7965
Practice Address - Fax:815-838-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL559010Medicare PIN