Provider Demographics
NPI:1922188986
Name:ANDREA M. BACON, M.D. LTD.
Entity Type:Organization
Organization Name:ANDREA M. BACON, M.D. LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-350-7717
Mailing Address - Street 1:820 DAVIS ST
Mailing Address - Street 2:#450
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4431
Mailing Address - Country:US
Mailing Address - Phone:847-425-7400
Mailing Address - Fax:847-328-1295
Practice Address - Street 1:701 S WELLS ST
Practice Address - Street 2:#2902
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4640
Practice Address - Country:US
Practice Address - Phone:773-350-7717
Practice Address - Fax:312-663-3740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG19759Medicare UPIN