Healthcare Provider Details

I. General information

NPI: 1598767352
Provider Name (Legal Business Name): ANDREW IVANCHENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 S. BUFFALO GROVE ROAD
BUFFALO GROVE IL
60089
US

IV. Provider business mailing address

235 MORAINE RD
HIGHLAND PARK IL
60202-2374
US

V. Phone/Fax

Practice location:
  • Phone: 847-681-1161
  • Fax: 847-681-1161
Mailing address:
  • Phone: 224-628-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number36111777
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36111777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: