Healthcare Provider Details

I. General information

NPI: 1871898379
Provider Name (Legal Business Name): GERASIM TIKOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 S. FEDERAL ST.
CHICAGO IL
60605-2724
US

IV. Provider business mailing address

1429 S. FEDERAL ST.
CHICAGO IL
60605-2724
US

V. Phone/Fax

Practice location:
  • Phone: 312-294-9903
  • Fax:
Mailing address:
  • Phone: 312-294-9903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-036982
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: