Basic Information
| Provider Information | |||||||||
| NPI: | 1568409480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERIC BESSONNY SC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8135 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607142828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479678098 | ||||||||
| FaxNumber: | 8479678594 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 W IL ROUTE 22 | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600107509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473819600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | BESSONNY | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8479671149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01626522 | 01 | IL | BLUE SHIELD OF ILLINOIS | OTHER |