Healthcare Provider Details

I. General information

NPI: 1164688941
Provider Name (Legal Business Name): IGOR V KOLESNIKOV MD, PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 02/02/2024
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

2146 RUGEN RD APT B
GLENVIEW IL
60026-5520
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax:
Mailing address:
  • Phone: 847-962-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051287029
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125051239
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036-123253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: