Healthcare Provider Details

I. General information

NPI: 1942291604
Provider Name (Legal Business Name): VITALIY Y. POYLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 16
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

259 E ERIE ST FL 16
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6868
  • Fax: 312-695-2729
Mailing address:
  • Phone: 312-695-6868
  • Fax: 312-695-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number225056
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number03149083
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: