Provider Demographics
NPI:1770638959
Name:STEPHEN J BUNDRA MD SC
Entity type:Organization
Organization Name:STEPHEN J BUNDRA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUNDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-853-9104
Mailing Address - Street 1:1921 LAKE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1480
Mailing Address - Country:US
Mailing Address - Phone:847-853-9104
Mailing Address - Fax:
Practice Address - Street 1:1921 LAKE AVE STE B
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1480
Practice Address - Country:US
Practice Address - Phone:847-853-9104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC37804Medicare UPIN
208735Medicare PIN