MEDICARE: DR. BRADLEY LANE ASHPOLE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	036113854	IL

General Provider Information

NPI Number	:	1457516866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY LANE ASHPOLE M.D.

Provider Business Mailing Address
First Line	:	1333 W ESTATE LN E
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-3623
Country	:	US
Telephone Number	:	847-650-5818
Fax Number	:	312-660-8837

Provider Business Practice Location Address
First Line	:	1107 N PROSPECT AVE
Second Line	:
City	:	ITASCA
State	:	IL
Zip	:	60143-1408
Country	:	US
Telephone Number	:	847-884-8346
Fax Number	:	847-739-0969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	05/10/2024

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