Provider Demographics
NPI:1629243282
Name:DR EVELYN G BASCO MD, SC
Entity Type:Organization
Organization Name:DR EVELYN G BASCO MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM ASSIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILYFLOR
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-737-8818
Mailing Address - Street 1:3900 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2354
Mailing Address - Country:US
Mailing Address - Phone:773-533-3440
Mailing Address - Fax:773-884-8117
Practice Address - Street 1:3900 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2354
Practice Address - Country:US
Practice Address - Phone:773-533-3440
Practice Address - Fax:773-884-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055675208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1235373853OtherGROUP NPI
IL036055675Medicaid
IL036055675Medicaid
IL493950Medicare PIN