Healthcare Provider Details

I. General information

NPI: 1245531904
Provider Name (Legal Business Name): ALEXANDRA ILKIW AND ANDREW ILKIW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-6082
  • Fax:
Mailing address:
  • Phone: 773-631-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036042994
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036061714
License Number StateIL

VIII. Authorized Official

Name: ALEXANDRA ILKIW
Title or Position: OWNER
Credential: M.D.
Phone: 773-631-6082