MEDICARE: MRS. JOANNE SIM BAVELIS PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085001689	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	776530	OTHER	IL	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1063406718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOANNE SIM BAVELIS PAC

Provider Business Mailing Address
First Line	:	777 N MICHIGAN AVE
Second Line	:	APT 2301
City	:	CHICAGO
State	:	IL
Zip	:	60611-2617
Country	:	US
Telephone Number	:	850-543-8906
Fax Number	:

Provider Business Practice Location Address
First Line	:	676 N SAINT CLAIR ST
Second Line	:	19TH FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60611-2927
Country	:	US
Telephone Number	:	312-926-3205
Fax Number	:	312-695-0042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	12/29/2010

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Directions to “ MRS. JOANNE SIM BAVELIS PAC” Practice Location

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