Basic Information
| Provider Information | |||||||||
| NPI: | 1265545446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCCELLATO | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701206 | ||||||||
| FaxNumber: | 8475701248 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600614304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479417900 | ||||||||
| FaxNumber: | 8479417902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036095967 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.