Healthcare Provider Details

I. General information

NPI: 1154974590
Provider Name (Legal Business Name): OSIPOVA SURGICAL SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W SURF ST STE 714
CHICAGO IL
60657-7227
US

IV. Provider business mailing address

1S376 SUMMIT AVE STE 4C
OAKBROOK TERRACE IL
60181-3966
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-7911
  • Fax:
Mailing address:
  • Phone: 630-424-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA OSIPOVA
Title or Position: OWNER
Credential: MD
Phone: 773-561-7911