Basic Information
| Provider Information | |||||||||
| NPI: | 1346275492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDGREN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E CHICAGO AVE # 24 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 E CHICAGO AVE # 24 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036085394 | IL | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 036085394 | IL | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 036085394 | 05 | IL | MEDICAID |