Healthcare Provider Details

I. General information

NPI: 1609068402
Provider Name (Legal Business Name): MARK JAY BAILIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 N MAGNOLIA AV. GARDEN OR BASEMENT APT.
CHICAGO IL
60660-1945
US

IV. Provider business mailing address

6238 N MAGNOLIA AV. GARDEN OR BASEMENT APT.
CHICAGO IL
60660-1945
US

V. Phone/Fax

Practice location:
  • Phone: 773-262-2647
  • Fax: 773-262-2647
Mailing address:
  • Phone: 773-262-2647
  • Fax: 773-262-2647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-069-383
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036069383
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036-069-383
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036-069-383
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-069-383
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036069383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: