Provider Demographics
NPI:1821204082
Name:SUBURBAN OTOLARYNGOLOGY,S.C.
Entity Type:Organization
Organization Name:SUBURBAN OTOLARYNGOLOGY,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-749-3070
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040148033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL605740Medicare PIN