=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285154773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEIRDRE MCCOLGAN BARTLETT MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2017
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 E CHICAGO AVE BOX #37
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-227-6160
-----------------------------------------------------
Fax | 312-227-9405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 E CHICAGO AVE BOX #37
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-227-6160
-----------------------------------------------------
Fax | 312-227-9405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301112357
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 036156792
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------