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General NPI Number Information
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NPI Number | 1154850972
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Entity Type | Organization
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Legal Business Name | POLYKARPOS ANESTHESIA LLC
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Dates
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Enumeration Date | 06/06/2017
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Last Update Date | 06/06/2017
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Provider Practice Location Address
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Address Line | 8400 LAKEVIEW PKWY STE 800
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-5819
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Country | US
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Telephone | 705-275-7799
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Fax |
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Provider Business Mailing Address
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Address Line | 825 N SHERIDAN RD
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City | LAKE FOREST
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State | IL
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Zip | 60045-2226
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | ARISTEIDIE DIVERIS
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Credential | MD
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Telephone | 847-309-9896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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