Provider Demographics
NPI:1821187923
Name:BAILEY, LARRY L (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3420
Mailing Address - Country:US
Mailing Address - Phone:708-749-3070
Mailing Address - Fax:708-749-3410
Practice Address - Street 1:3340 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3420
Practice Address - Country:US
Practice Address - Phone:708-749-3070
Practice Address - Fax:708-749-3410
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-048178207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-048178Medicaid
IL036-048178Medicaid