Basic Information
| Provider Information | |||||||||
| NPI: | 1104321272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3231 EUCLID AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604024603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087832000 | ||||||||
| FaxNumber: | 7087833656 | ||||||||
| Practice Location | |||||||||
| Address1: | 6434 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607074030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738363000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125.071794 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036157305 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.