Healthcare Provider Details

I. General information

NPI: 1518223791
Provider Name (Legal Business Name): HANSEL M DEBARTOLO JR MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 DEBARTOLO DR.
SUGAR GROVE IL
60554
US

IV. Provider business mailing address

11 DEBARTOLO DR.
SUGAR GROVE IL
60554
US

V. Phone/Fax

Practice location:
  • Phone: 630-859-1818
  • Fax: 630-859-1830
Mailing address:
  • Phone: 630-859-1818
  • Fax: 630-859-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036-054436
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036-054436
License Number StateIL

VIII. Authorized Official

Name: HANSEL M DEBARTOLO JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 630-859-1818