Healthcare Provider Details

I. General information

NPI: 1780620864
Provider Name (Legal Business Name): THEODORE M WYNNYCHENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE DEPARTMENT OF ANESTHESIA
EVANSTON IL
60201
US

IV. Provider business mailing address

450 W IL ROUTE 22 DEPT OF
BARRINGTON IL
60010-1919
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-381-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number036100119
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number036100119
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036100119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: