Healthcare Provider Details

I. General information

NPI: 1710720396
Provider Name (Legal Business Name): LIOR COHEN YATZIV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LIOR COHEN M.D

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W. TAYLOR ST.
CHICAGO IL
60612
US

IV. Provider business mailing address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax: 312-413-1657
Mailing address:
  • Phone: 312-413-1657
  • Fax: 312-413-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number125083605
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: