Healthcare Provider Details

I. General information

NPI: 1538265616
Provider Name (Legal Business Name): ERT FAMILY PRACTICE, S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OGDEN AVE
AURORA IL
60504-7222
US

IV. Provider business mailing address

4828 LINSCOTT AVE
DOWNERS GROVE IL
60515-3539
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-4810
  • Fax:
Mailing address:
  • Phone: 630-915-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number109696
License Number StateIL

VIII. Authorized Official

Name: DR. MICHELLE ANN BARDACK
Title or Position: PRESIDENT
Credential: MD
Phone: 630-915-4019