Healthcare Provider Details

I. General information

NPI: 1689687527
Provider Name (Legal Business Name): BOFFA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 N CALIFORNIA AVE SUITE 780
CHICAGO IL
60625-3645
US

IV. Provider business mailing address

5140 N CALIFORNIA AVE SUITE 780
CHICAGO IL
60625-3645
US

V. Phone/Fax

Practice location:
  • Phone: 773-273-6810
  • Fax: 773-273-5532
Mailing address:
  • Phone: 773-273-6810
  • Fax: 773-273-5532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JAMES FRANK BOFFA
Title or Position: PARTNER
Credential: MD
Phone: 773-273-6810