Healthcare Provider Details

I. General information

NPI: 1174935274
Provider Name (Legal Business Name): ANN BUNYAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3722 HARLEM AVE SUITE LL34
RIVERSIDE IL
60546-2312
US

IV. Provider business mailing address

2920 W BERWYN AVE APT 1
CHICAGO IL
60625-4027
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-6566
  • Fax:
Mailing address:
  • Phone: 312-315-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036142467
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: