Provider Demographics
NPI:1932141637
Name:BACOM, CECELIA B (CNM)
Entity Type:Individual
Prefix:
First Name:CECELIA
Middle Name:B
Last Name:BACOM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1108
Mailing Address - Country:US
Mailing Address - Phone:708-386-0845
Mailing Address - Fax:708-386-8472
Practice Address - Street 1:6201 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1108
Practice Address - Country:US
Practice Address - Phone:708-386-0845
Practice Address - Fax:708-386-8472
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001981367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209001981Medicaid