=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871605857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE R SOSENKO MD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3825 HIGHLAND AVE SUITE 2A
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-725-9700
-----------------------------------------------------
Fax | 630-725-9703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 OAKMONT LN SUITE 1600
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-5511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-789-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | GEORGE SOSENKO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-725-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------