Healthcare Provider Details

I. General information

NPI: 1316947062
Provider Name (Legal Business Name): SEBOUH A GUEYIKIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/14/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPARTMENT OF RADIOLOGY
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPARTMENT OF RADIOLOGY
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2475
  • Fax: 847-570-2942
Mailing address:
  • Phone: 847-570-2475
  • Fax: 847-570-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-103347
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036-103347
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: