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General NPI Number Information
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NPI Number | 1598931198
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Entity Type | Organization
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Legal Business Name | LARISSA BERESTENKO MD SC
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Dates
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Enumeration Date | 05/03/2008
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Last Update Date | 05/03/2008
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Provider Practice Location Address
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Address Line | 5140 N CALIFORNIA AVE STE 755
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City | CHICAGO
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State | IL
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Zip | 60625-7065
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Country | US
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Telephone | 773-271-9786
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Fax | 773-217-8028
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Provider Business Mailing Address
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Address Line | 2760 WILSHIRE LN
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City | NORTHBROOK
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State | IL
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Zip | 60062-2631
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Country | US
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Telephone | 773-271-9786
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Fax | 773-271-8028
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Authorized Official
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Title or Position | PRESIDENT
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Name | LARISSA BERESTENKO
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Credential | MD
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Telephone | 773-271-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 036101565
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License Number State | IL
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