Healthcare Provider Details

I. General information

NPI: 1538713441
Provider Name (Legal Business Name): GINA BARBAGLIA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 625
PARK RIDGE IL
60068-1137
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1810
US

V. Phone/Fax

Practice location:
  • Phone: 844-376-3876
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007132
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: