Provider Demographics
NPI:1952414682
Name:BANNEN, TODD W (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:W
Last Name:BANNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 W BALMORAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1005
Mailing Address - Country:US
Mailing Address - Phone:773-531-0674
Mailing Address - Fax:
Practice Address - Street 1:450 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1919
Practice Address - Country:US
Practice Address - Phone:847-842-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36099334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine