Provider Demographics
NPI:1063406718
Name:BAVELIS, JOANNE SIM (PAC)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:SIM
Last Name:BAVELIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N MICHIGAN AVE
Mailing Address - Street 2:APT 2301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2617
Mailing Address - Country:US
Mailing Address - Phone:850-543-8906
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:19TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-926-3205
Practice Address - Fax:312-695-0042
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001689363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL776530OtherMEDICARE GROUP NUMBER
ILK25142Medicare ID - Type Unspecified
IL776530OtherMEDICARE GROUP NUMBER