Healthcare Provider Details

I. General information

NPI: 1124064696
Provider Name (Legal Business Name): IGOR TKACHENKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE MC 4028
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

100 W CHESTNUT ST APT 2109
CHICAGO IL
60610-3225
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-9804
  • Fax:
Mailing address:
  • Phone: 312-640-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number223196
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number036116881
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number03611881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: