Basic Information
| Provider Information | |||||||||
| NPI: | 1164433181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOFFA | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOFFA | ||||||||
| OtherFirstName: | JAMES | ||||||||
| OtherMiddleName: | FRANK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE STE 1223 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702040 | ||||||||
| FaxNumber: | 8477335315 | ||||||||
| Practice Location | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732715532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036086529 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036086529 4 | 05 | IL | MEDICAID | 5077503 | 01 | IL | AETNA | OTHER | 036086529 2 | 05 | IL | MEDICAID | 0001630046 | 01 | IL | BC BS OF IL | OTHER |