Healthcare Provider Details

I. General information

NPI: 1386196590
Provider Name (Legal Business Name): EVAN SISMOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 16-738
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 16-738
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-5600
  • Fax: 847-535-7203
Mailing address:
  • Phone: 847-234-5600
  • Fax: 847-535-7203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA058746
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006711
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: