Healthcare Provider Details

I. General information

NPI: 1932141637
Provider Name (Legal Business Name): CECELIA B BACOM CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 ROOSEVELT RD
BERWYN IL
60402-1108
US

IV. Provider business mailing address

6201 ROOSEVELT RD
BERWYN IL
60402-1108
US

V. Phone/Fax

Practice location:
  • Phone: 708-386-0845
  • Fax: 708-386-8472
Mailing address:
  • Phone: 708-386-0845
  • Fax: 708-386-8472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209001981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: