Provider Demographics
NPI:1669531679
Name:BASCO, EVELYN GANADEN (MD)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:GANADEN
Last Name:BASCO
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 1:3900 W MADISON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624
Mailing Address - Country:US
Mailing Address - Phone:773-533-3440
Mailing Address - Fax:773-722-1200
Practice Address - Street 1:3900 W MADISON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624
Practice Address - Country:US
Practice Address - Phone:773-533-3440
Practice Address - Fax:773-722-1200
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-055675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055675Medicaid
IL036055675Medicaid
D13176Medicare UPIN