Healthcare Provider Details

I. General information

NPI: 1376682476
Provider Name (Legal Business Name): ALEXANDER EDUARD OBOLSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 1260
CHICAGO IL
60604-3631
US

IV. Provider business mailing address

53 W JACKSON BLVD STE 1260
CHICAGO IL
60604-3631
US

V. Phone/Fax

Practice location:
  • Phone: 312-456-4343
  • Fax: 312-456-8304
Mailing address:
  • Phone: 312-456-4343
  • Fax: 312-456-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036081074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: