Healthcare Provider Details

I. General information

NPI: 1205285855
Provider Name (Legal Business Name): DIMITRI BAGROV C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2016
Last Update Date: 06/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 BARRINGTON RD #1400
HOFFMAN ESTATES IL
60169-1019
US

IV. Provider business mailing address

14 N DRYDEN PL
ARLINGTON HEIGHTS IL
60004-6304
US

V. Phone/Fax

Practice location:
  • Phone: 847-836-7015
  • Fax:
Mailing address:
  • Phone: 347-992-0490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041.418064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: