=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538185095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ARNOLD M HERSKOVIC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 N LAKE SHORE DR 418
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-654-0051
-----------------------------------------------------
Fax | 312-942-2894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 N LAKE SHORE DR 418
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-654-0051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036097303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 5146-320
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 036097303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0203X
-----------------------------------------------------
Taxonomy Name | Therapeutic Radiology Physician
-----------------------------------------------------
License Number | EMC0006393
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036097303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 036-097303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------