Healthcare Provider Details

I. General information

NPI: 1336362631
Provider Name (Legal Business Name): MR. MICHAEL ALAN BANGHART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W WASHINGTON BLVD STE 401
CHICAGO IL
60612-2127
US

IV. Provider business mailing address

824 S TAYLOR AVE
OAK PARK IL
60304-1626
US

V. Phone/Fax

Practice location:
  • Phone: 773-645-8900
  • Fax:
Mailing address:
  • Phone: 773-841-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.002258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: