MEDICARE: LONGEVITY CENTERS OF ILLINOIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207RI0011X	Interventional Cardiology Physician
2	2085R0204X	Vascular & Interventional Radiology Physician
3	261QP2300X	Primary Care Clinic/Center
4	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1093427593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGEVITY CENTERS OF ILLINOIS LLC

Provider Business Mailing Address
First Line	:	PO BOX 451
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60065-0451
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 N LAKE ST STE 1
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-1827
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	YAN KATSNELSON
Credential	:
Telephone Number	:	847-774-5300

Provider Enumeration Date	:	12/16/2022
Last Update Date	:	04/16/2024

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