Healthcare Provider Details

I. General information

NPI: 1356518435
Provider Name (Legal Business Name): ROBERT MILTON BUMSTED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 340
CHICAGO IL
60612-3852
US

IV. Provider business mailing address

1725 W HARRISON ST STE 340
CHICAGO IL
60612-3852
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-6715
  • Fax: 312-563-0165
Mailing address:
  • Phone: 312-664-6715
  • Fax: 312-563-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36-074514
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: