1235294398 NPI number — LEONID AYZENBERG, M.D. INC

Table of content: (NPI 1235294398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235294398 NPI number — LEONID AYZENBERG, M.D. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEONID AYZENBERG, M.D. INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EYE CLINIC LEONID AYZENBERG MD INC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235294398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 E. RAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PROSPECT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60056-1508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-537-6800
Provider Business Mailing Address Fax Number:
847-556-8847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 E. RAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT PROSPECT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60056-1508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-537-6800
Provider Business Practice Location Address Fax Number:
847-556-8847
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AYZENBERG
Authorized Official First Name:
LEONID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
847-537-6800

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ========= . This is a "TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036095153 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1622332 . This is a "BS & BS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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