Healthcare Provider Details

I. General information

NPI: 1417444084
Provider Name (Legal Business Name): BIANCA FELICIA RAD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

6140 N HARDING AVE
CHICAGO IL
60659-3108
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4150
  • Fax:
Mailing address:
  • Phone: 773-592-9310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036157304
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: