Provider Demographics
NPI:1518223791
Name:HANSEL M DEBARTOLO JR MD SC
Entity Type:Organization
Organization Name:HANSEL M DEBARTOLO JR MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HANSEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEBARTOLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:630-859-1818
Mailing Address - Street 1:11 DEBARTOLO DR.
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554
Mailing Address - Country:US
Mailing Address - Phone:630-859-1818
Mailing Address - Fax:630-859-1830
Practice Address - Street 1:11 DEBARTOLO DR.
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554
Practice Address - Country:US
Practice Address - Phone:630-859-1818
Practice Address - Fax:630-859-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054436207Y00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL248210Medicare PIN
D10295Medicare UPIN
ILD10295Medicare UPIN
248210Medicare PIN