Healthcare Provider Details

I. General information

NPI: 1518576230
Provider Name (Legal Business Name): BO HENRY MARSHALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 2100
CHICAGO IL
60611-2993
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 2100
CHICAGO IL
60611-2993
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-1800
  • Fax: 312-695-4741
Mailing address:
  • Phone: 312-695-1800
  • Fax: 312-695-4741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011616
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5799
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: