=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811158504
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARTLEY GARVER THORNBURG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 04/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 E HURON ST FEINBERG 4-710 - DEPT OF RADIOLOGY
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-926-5113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 E HURON ST DEPARTMENT OF RADIOLOGY, FEINBERG 4-710
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 036.132888
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------