1154562080 NPI number — DR. ROY JAMES BARDWELL JR. D.O.

Table of content: WENDY ALEJANDRO (NPI 1073337028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154562080 NPI number — DR. ROY JAMES BARDWELL JR. D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARDWELL
Provider First Name:
ROY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154562080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16650 HARLEM AVENUE
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-7241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-802-9355
Provider Business Mailing Address Fax Number:
708-904-4504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16650 HARLEM AVE
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
TINLEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60477-1847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-802-9355
Provider Business Practice Location Address Fax Number:
708-904-4504
Provider Enumeration Date:
03/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036124712 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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