Healthcare Provider Details

I. General information

NPI: 1538275508
Provider Name (Legal Business Name): YURIY SEREMBYTSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 09/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11255 W PLAINFIELD RD
INDIAN HEAD PARK IL
60525-3735
US

IV. Provider business mailing address

11255 W PLAINFIELD RD
INDIAN HEAD PARK IL
60525-3735
US

V. Phone/Fax

Practice location:
  • Phone: 708-420-3203
  • Fax:
Mailing address:
  • Phone: 708-420-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number238.000044
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238.000044
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: