Provider Demographics
NPI:1598086399
Name:BERNADETTE B MAYER MD SC
Entity Type:Organization
Organization Name:BERNADETTE B MAYER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:773-775-6181
Mailing Address - Street 1:5365 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4142
Mailing Address - Country:US
Mailing Address - Phone:773-775-6181
Mailing Address - Fax:773-775-4699
Practice Address - Street 1:5365 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4142
Practice Address - Country:US
Practice Address - Phone:773-775-6181
Practice Address - Fax:773-775-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067899261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572110Medicare PIN