Healthcare Provider Details

I. General information

NPI: 1780992578
Provider Name (Legal Business Name): ALEXANDER KNIJNIKOV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 N. HARLEM AVE. SUBURBAN SURGERY CENTER
ELMWOOD PARK IL
60707-3717
US

IV. Provider business mailing address

1950 N. HARLEM AVE. SUBURBAN SURGERY CENTER
ELMWOOD PARK IL
60707-3717
US

V. Phone/Fax

Practice location:
  • Phone: 708-453-6800
  • Fax: 708-453-3985
Mailing address:
  • Phone: 708-453-6800
  • Fax: 708-453-3985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.140156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: