Healthcare Provider Details

I. General information

NPI: 1154670198
Provider Name (Legal Business Name): ELIZABETH BAILEY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

3424 KOSSUTH AVE
BRONX NY
10467-2410
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 718-519-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7962132
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: