Basic Information
| Provider Information | |||||||||
| NPI: | 1265987440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACOS | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8701 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149554578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 E HURON ST | ||||||||
| Address2: | SUITE 1-200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125037975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2016 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | B22043894236 | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.