Healthcare Provider Details

I. General information

NPI: 1912078759
Provider Name (Legal Business Name): TARAS MASNYK MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD RD ASP #500
WINFIELD IL
60190
US

IV. Provider business mailing address

25 N WINFIELD RD ASP #500
WINFIELD IL
60190-1222
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4056
  • Fax: 630-933-4057
Mailing address:
  • Phone: 630-933-4056
  • Fax: 630-933-4057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number10794
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036-098187
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: