Healthcare Provider Details

I. General information

NPI: 1417375635
Provider Name (Legal Business Name): BOGDAN ISAILA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 7-335
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 7-335
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0419
  • Fax: 312-926-3127
Mailing address:
  • Phone: 312-695-0419
  • Fax: 312-926-3127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number125066003
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number036154195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: