MEDICARE: ANDREA M. BACON, M.D. LTD.

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	2084P0800X	Psychiatry Physician		IL

General Provider Information

NPI Number	:	1922188986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREA M. BACON, M.D. LTD.

Provider Business Mailing Address
First Line	:	820 DAVIS ST
Second Line	:	#450
City	:	EVANSTON
State	:	IL
Zip	:	60201-4431
Country	:	US
Telephone Number	:	847-425-7400
Fax Number	:	847-328-1295

Provider Business Practice Location Address
First Line	:	701 S WELLS ST
Second Line	:	#2902
City	:	CHICAGO
State	:	IL
Zip	:	60607-4640
Country	:	US
Telephone Number	:	773-350-7717
Fax Number	:	312-663-3740

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANDREA MICHELLE BACON
Credential	:	M.D.
Telephone Number	:	773-350-7717

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	08/22/2020

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