Basic Information
| Provider Information | |||||||||
| NPI: | 1689687527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOFFA MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | BOFFA SURGICAL GROUP, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735532 | ||||||||
| Practice Location | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOFFA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | FRANK | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7732736810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0001630046 | 01 | IL | BCBS OF IL GROUP NUMBER | OTHER |