Healthcare Provider Details

I. General information

NPI: 1871171157
Provider Name (Legal Business Name): RYAN BUNNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 N ELSTON AVE STE 110
CHICAGO IL
60642-1501
US

IV. Provider business mailing address

1765 N ELSTON AVE STE 110
CHICAGO IL
60642-1501
US

V. Phone/Fax

Practice location:
  • Phone: 773-276-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125.078851
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: