Provider Demographics
NPI:1689687527
Name:BOFFA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BOFFA MEDICAL GROUP LLC
Other - Org Name:BOFFA SURGICAL GROUP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:BOFFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-273-6810
Mailing Address - Street 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE 780
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-273-6810
Mailing Address - Fax:773-273-5532
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 780
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-273-6810
Practice Address - Fax:773-273-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001630046OtherBCBS OF IL GROUP NUMBER
IL686000Medicare PIN
ILCK4266Medicare PIN
IL203198Medicare PIN