Provider Demographics
NPI:1437357795
Name:ANDREA BAZAN, M.D, S.C
Entity Type:Organization
Organization Name:ANDREA BAZAN, M.D, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-575-0613
Mailing Address - Street 1:345 WEST 24TH PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2229
Mailing Address - Country:US
Mailing Address - Phone:773-575-0613
Mailing Address - Fax:847-299-7844
Practice Address - Street 1:1600 WEST DEMPSTER STREET
Practice Address - Street 2:SUITE #120
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-299-7888
Practice Address - Fax:847-299-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095548207R00000X
IL036-095548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095548Medicaid
IL036095548Medicaid
IL215614Medicare PIN
IL206608Medicare PIN