Healthcare Provider Details

I. General information

NPI: 1619327392
Provider Name (Legal Business Name): RIYA BASU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD
CHICAGO IL
60612-3276
US

IV. Provider business mailing address

700 W VAN BUREN ST APT 1406
CHICAGO IL
60607-3619
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2200
  • Fax:
Mailing address:
  • Phone: 404-631-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.069230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: