Healthcare Provider Details

I. General information

NPI: 1205190576
Provider Name (Legal Business Name): BRIDGET S BANACH M.D. PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2012
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE RM P-615 MC6101
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

5841 S MARYLAND AVE RM P-615 MC6101
CHICAGO IL
60637-1447
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-7708
  • Fax:
Mailing address:
  • Phone: 773-834-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number125061495
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036137292
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: