Healthcare Provider Details

I. General information

NPI: 1144280785
Provider Name (Legal Business Name): RANDALL SCOTT YESSENOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 E DELAWARE PL STE 1400
CHICAGO IL
60611-1806
US

IV. Provider business mailing address

PO BOX 405
SCHERERVILLE IN
46375-0405
US

V. Phone/Fax

Practice location:
  • Phone: 312-202-9909
  • Fax:
Mailing address:
  • Phone: 219-742-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01039206
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036.086614
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: