1811547375 NPI number — ELENA VLADIMIROVNA MEDYANIK PHYSICIANS ASSISTAN

Table of content: ELENA VLADIMIROVNA MEDYANIK PHYSICIANS ASSISTAN (NPI 1811547375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811547375 NPI number — ELENA VLADIMIROVNA MEDYANIK PHYSICIANS ASSISTAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDYANIK
Provider First Name:
ELENA
Provider Middle Name:
VLADIMIROVNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIANS ASSISTAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1811547375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22285 N PEPPER RD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE BARRINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60010-2540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-382-5080
Provider Business Mailing Address Fax Number:
847-382-0923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22285 N PEPPER RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE BARRINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60010-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-382-5080
Provider Business Practice Location Address Fax Number:
847-382-0923
Provider Enumeration Date:
09/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085007121 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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