Provider Demographics
NPI:1194763433
Name:BACON, ANDREA (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19530 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1778
Mailing Address - Country:US
Mailing Address - Phone:708-799-2200
Mailing Address - Fax:708-922-4455
Practice Address - Street 1:19530 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1778
Practice Address - Country:US
Practice Address - Phone:708-799-2200
Practice Address - Fax:708-922-4455
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG19759Medicare UPIN