=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124064696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IGOR TKACHENKO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S MARYLAND AVE MC 4028
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-834-9804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 W CHESTNUT ST APT 2109
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-3225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-640-0339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 223196
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | 036116881
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 03611881
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------