=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316345077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW PETER KRIVOSHIK M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2014
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 E CENTER AVE
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-735-9737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 E CENTER AVE
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-735-9737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 1015840
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 200200389
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 42674
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 036111634
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301113666
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 69592-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | 200200389
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 208U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Pharmacology Physician
-----------------------------------------------------
License Number | 1015840
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 208U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Pharmacology Physician
-----------------------------------------------------
License Number | 036111634
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------