Provider Demographics
NPI:1457487415
Name:BAZELL, GREGORY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:BAZELL
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 1:20 EXECUTIVE CT
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9543
Mailing Address - Country:US
Mailing Address - Phone:847-382-4160
Mailing Address - Fax:
Practice Address - Street 1:20 EXECUTIVE CT
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9543
Practice Address - Country:US
Practice Address - Phone:847-382-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103581208200000X
CAG86115208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK22919Medicare UPIN