Healthcare Provider Details

I. General information

NPI: 1154850972
Provider Name (Legal Business Name): POLYKARPOS ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 LAKEVIEW PKWY STE 800
PLEASANT PRAIRIE WI
53158-5819
US

IV. Provider business mailing address

825 N SHERIDAN RD
LAKE FOREST IL
60045-2226
US

V. Phone/Fax

Practice location:
  • Phone: 705-275-7799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ARISTEIDIE DIVERIS
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 847-309-9896