Basic Information
| Provider Information | |||||||||
| NPI: | 1447211966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERYLO | ||||||||
| FirstName: | BOGDAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2608 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606185905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 8669545804 | ||||||||
| Practice Location | |||||||||
| Address1: | 2608 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606185905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 8669545804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22935 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 22935 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036122336 | 05 | IL | MEDICAID |