Healthcare Provider Details

I. General information

NPI: 1104056449
Provider Name (Legal Business Name): SERGUEI V KISHKURNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST # 250N
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5722
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01067835A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-125524
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01067835A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number244975
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: