Provider Demographics
NPI:1356367601
Name:BIRD, COLLEEN (PA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BIRD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-3269
Mailing Address - Country:US
Mailing Address - Phone:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:2631 WILLIAMSBURG AVE STE 302
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1128
Practice Address - Country:US
Practice Address - Phone:630-377-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL206147103OtherMEDICARE PTAN (INDIVIDUAL)
ILP01209459OtherMEDICARE RAILROAD (PROVIDER PTAN)
ILCA4748OtherMEDICARE RAILROAD (GROUPPTAN)
IL206147103OtherMEDICARE PTAN (INDIVIDUAL)