Basic Information
| Provider Information | |||||||||
| NPI: | 1841501962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HO | ||||||||
| FirstName: | BRYANT | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 E ERIE ST | ||||||||
| Address2: | APT 2208 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138185069 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303236116 | ||||||||
| FaxNumber: | 6303236169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | 036133109 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IL | MEDICAID |