Provider Demographics
NPI:1942287479
Name:MILA C R BACALLA MD SC
Entity Type:Organization
Organization Name:MILA C R BACALLA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILA C
Authorized Official - Middle Name:R
Authorized Official - Last Name:BACALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-227-5707
Mailing Address - Street 1:4459 W JARVIS AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1813
Mailing Address - Country:US
Mailing Address - Phone:773-227-5707
Mailing Address - Fax:847-675-1131
Practice Address - Street 1:2222 W DIVISION
Practice Address - Street 2:SUITE 340
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3086
Practice Address - Country:US
Practice Address - Phone:773-227-5707
Practice Address - Fax:847-675-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
470540Medicare ID - Type Unspecified
C41804Medicare UPIN