Healthcare Provider Details

I. General information

NPI: 1821098542
Provider Name (Legal Business Name): SHELLY LYNNE BLEDSOE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 E 75TH ST
CHICAGO IL
60649-3306
US

IV. Provider business mailing address

808 MERRY LN
OAK BROOK IL
60523-1420
US

V. Phone/Fax

Practice location:
  • Phone: 773-731-0014
  • Fax: 773-731-2034
Mailing address:
  • Phone: 630-586-9930
  • Fax: 630-530-9425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: