=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669597910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTON J. SAHATTCHIEV RSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5722 W MAPLE AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60163-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-691-9982
-----------------------------------------------------
Fax | 708-544-3807
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5722 W MAPLE AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60163-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-691-9982
-----------------------------------------------------
Fax | 708-544-3807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------