Healthcare Provider Details

I. General information

NPI: 1447302104
Provider Name (Legal Business Name): VADIM YALOVETSKIY CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 09/03/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ASCENSION ALEXIAN BROTHER MEDICAL CENTER 800 BIESTERFIELD RD
ELK GROVE VILLAGE IL
60007-3361
US

IV. Provider business mailing address

567 GREENWOOD ROAD
GLENVIEW IL
60025-4572
US

V. Phone/Fax

Practice location:
  • Phone: 847-437-5500
  • Fax: 847-904-7285
Mailing address:
  • Phone: 847-904-7315
  • Fax: 847-904-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: