Healthcare Provider Details

I. General information

NPI: 1013993914
Provider Name (Legal Business Name): SAMUEL DOREVITCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 REMITTANCE DR SUITE 1951
CHICAGO IL
60675-1001
US

IV. Provider business mailing address

5336 N LAKEWOOD AVE
CHICAGO IL
60640-2209
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-5917
  • Fax: 847-535-5801
Mailing address:
  • Phone: 773-334-9029
  • Fax: 312-996-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36083148
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: