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General NPI Number Information
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NPI Number | 1518223791
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Entity Type | Organization
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Legal Business Name | HANSEL M DEBARTOLO JR MD SC
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Dates
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Enumeration Date | 04/02/2012
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Last Update Date | 05/08/2012
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Provider Practice Location Address
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Address Line | 11 DEBARTOLO DR.
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City | SUGAR GROVE
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State | IL
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Zip | 60554
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Country | US
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Telephone | 630-859-1818
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Fax | 630-859-1830
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Provider Business Mailing Address
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Address Line | 11 DEBARTOLO DR.
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City | SUGAR GROVE
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State | IL
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Zip | 60554
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Country | US
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Telephone | 630-859-1818
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Fax | 630-859-1830
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Authorized Official
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Title or Position | PRESIDENT
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Name | HANSEL M DEBARTOLO JR.
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Credential | MD
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Telephone | 630-859-1818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | 036-054436
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 036-054436
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License Number State | IL
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