=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912122383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELENA FITCHEV MD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 02/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 AUSTIN ST STE 502W
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-328-3213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 AUSTIN ST STE 502W
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-328-3213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELENA FITCHEV
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 847-328-3213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036092221
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------