Healthcare Provider Details

I. General information

NPI: 1790782613
Provider Name (Legal Business Name): RADA IVANOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 W ADDISON ST SUITE 304
CHICAGO IL
60634-4401
US

IV. Provider business mailing address

5600 W ADDISON ST SUITE 304
CHICAGO IL
60634-4401
US

V. Phone/Fax

Practice location:
  • Phone: 773-481-1570
  • Fax: 773-481-0547
Mailing address:
  • Phone: 773-481-1570
  • Fax: 773-481-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036089071
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036089071
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberM-2341
License Number StateGU
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01085124A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: