Provider Demographics
NPI:1578521175
Name:BIANCONI, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:BIANCONI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE B310
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8441
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-759-4692
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE B310
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-759-4692
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-088093OtherSTATE LICENSE
IL370022706OtherMEDICARE RAILROAD CARRIER
IL036-088093OtherSTATE LICENSE