Healthcare Provider Details

I. General information

NPI: 1346214459
Provider Name (Legal Business Name): BRYAN YANAGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W ROOSEVELT RD
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S 1ST AVE 101-1740 LOYOLA UNIVERSITY MEDICAL CENTER
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-531-7900
  • Fax: 708-531-5201
Mailing address:
  • Phone: 708-216-9000
  • Fax: 708-216-9033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36084003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: