Provider Demographics
NPI:1730174053
Name:BONGARD, RICHARD H (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
Last Name:BONGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TINLEY PARK MENTAL HEALTH CENTER
Mailing Address - Street 2:7400 WEST 183RD STREET
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3695
Mailing Address - Country:US
Mailing Address - Phone:708-614-4000
Mailing Address - Fax:
Practice Address - Street 1:TINLEY PARK MENTAL HEALTH CENTER
Practice Address - Street 2:7400 WEST 183RD STREET
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3695
Practice Address - Country:US
Practice Address - Phone:708-614-4000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36056637174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44418Medicare UPIN