Healthcare Provider Details

I. General information

NPI: 1215940598
Provider Name (Legal Business Name): YAKOV GERTSBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

900 S DAMEN AVE MENTAL HEALTH SERVICE LINE; DAY HOSPITAL
CHICAGO IL
60612-3730
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-569-6991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number036-100999
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036100999
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: