1750310553 NPI number — DR. ISMAIL BOBAT MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750310553 NPI number — DR. ISMAIL BOBAT MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BOBAT

Provider First Name:

ISMAIL

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1750310553

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5300 RELIABLE PKWY

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHICAGO

Provider Business Mailing Address State Name:

IL

Provider Business Mailing Address Postal Code:

60686-5300

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

708-633-1234

Provider Business Mailing Address Fax Number:

708-342-7272

Provider First Line Business Practice Location Address:

1400 WEST PARK ST

Provider Second Line Business Practice Location Address:

SUITE D2248

Provider Business Practice Location Address City Name:

URBANA

Provider Business Practice Location Address State Name:

IL

Provider Business Practice Location Address Postal Code:

61801-2396

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

217-337-3738

Provider Business Practice Location Address Fax Number:

217-337-4569

Provider Enumeration Date:

07/02/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RS0012X , with the licence number:  036-110991 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0200X , with the licence number: 036-110991 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RP1001X , with the licence number: 036110991 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: CA2264 . This is a "RR GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 036110991 . This is a "ILLINOIS MEDICAL LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 036110991 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 833120 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 35437 . This is a "IOWA MEDICAL LICENSE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 4301078417 . This is a "MICHIGAN MEDICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: P00446526 . This is a "RR INDIVIDUAL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".