Basic Information
| Provider Information | |||||||||
| NPI: | 1861064131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOVINO | ||||||||
| FirstName: | MARIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HARVESTER DR. | ||||||||
| Address2: | STE 300 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605276686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737026222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2021 | ||||||||
| LastUpdateDate: | 05/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125.078044 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | 125.078044 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.