MEDICARE: SERGEY SHUSHUNOV MD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036070073	IL
2	2080P0203X	Pediatric Critical Care Medicine Physician	036070073	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07215036	OTHER	IL	BCBS
2	IL0104	OTHER	IL	JOHN DEERE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588632681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGEY SHUSHUNOV MD

Provider Business Mailing Address
First Line	:	263 APPLETREE CT
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-2405
Country	:	US
Telephone Number	:	847-962-1858
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 W STATION ST
Second Line	:
City	:	SAINT ANNE
State	:	IL
Zip	:	60964-7251
Country	:	US
Telephone Number	:	815-427-1324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	08/22/2023

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