Provider Demographics
NPI:1447211966
Name:DERYLO, BOGDAN (MD)
Entity Type:Individual
Prefix:MR
First Name:BOGDAN
Middle Name:
Last Name:DERYLO
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 1:2608 W ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5905
Mailing Address - Country:US
Mailing Address - Phone:312-654-2700
Mailing Address - Fax:866-954-5804
Practice Address - Street 1:2608 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5905
Practice Address - Country:US
Practice Address - Phone:312-654-2700
Practice Address - Fax:866-954-5804
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22935207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122336Medicaid
IL036122336Medicaid
IL603040001Medicare UPIN