Healthcare Provider Details

I. General information

NPI: 1609009208
Provider Name (Legal Business Name): BRUNO VINCENT DECARIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2009
Last Update Date: 08/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

1934 N LEAVITT ST APARTMENT #2
CHICAGO IL
60647-4456
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 304-723-8457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125056820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: