Provider Demographics
NPI:1942288550
Name:BACALLA, MILA C R (MD)
Entity Type:Individual
Prefix:
First Name:MILA C
Middle Name:R
Last Name:BACALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4459 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:223-227-5707
Practice Address - Fax:847-675-1131
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3647298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41804Medicare UPIN
470540Medicare ID - Type Unspecified