Healthcare Provider Details

I. General information

NPI: 1003300682
Provider Name (Legal Business Name): BOBIEJO AVA FERGUSON BRYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC6040
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-4503
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax: 773-702-2140
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.072453
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: