Healthcare Provider Details

I. General information

NPI: 1255458055
Provider Name (Legal Business Name): DR. JUSTIN PAUL LEVISAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CENTRAL ST STE 730
EVANSTON IL
60201
US

IV. Provider business mailing address

1000 CENTRAL ST STE 730
EVANSTON IL
60201-1779
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-8410
  • Fax: 847-676-1727
Mailing address:
  • Phone: 847-663-8410
  • Fax: 847-676-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036105254
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036105254
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: