Provider Demographics
NPI:1962510537
Name:IFZAL K BANGASH M.D.S.C.
Entity Type:Organization
Organization Name:IFZAL K BANGASH M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IFZAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BANGASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-344-2300
Mailing Address - Street 1:4309 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:
Practice Address - Street 1:4314 W CRYSTAL LAKE RD
Practice Address - Street 2:SUITE D
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4211
Practice Address - Country:US
Practice Address - Phone:815-344-2300
Practice Address - Fax:815-344-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210108Medicare PIN