Healthcare Provider Details

I. General information

NPI: 1831116920
Provider Name (Legal Business Name): ELI LAVIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 WAUKEGAN RD SUITE 100
BANNOCKBURN IL
60015-1885
US

IV. Provider business mailing address

2151 WAUKEGAN RD SUITE 100
BANNOCKBURN IL
60015-1885
US

V. Phone/Fax

Practice location:
  • Phone: 847-444-5300
  • Fax: 847-267-0694
Mailing address:
  • Phone: 847-444-5300
  • Fax: 847-267-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36077799
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: