MEDICARE: EVASKUS AND HERZOG, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	060003037	IL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

General Provider Information

NPI Number	:	1316044837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVASKUS AND HERZOG, LTD

Provider Business Mailing Address
First Line	:	2440 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4113
Country	:	US
Telephone Number	:	773-761-7171
Fax Number	:	773-761-6714

Provider Business Practice Location Address
First Line	:	2440 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4113
Country	:	US
Telephone Number	:	773-761-7171
Fax Number	:	773-761-6714

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	JENNIFER PIETRI
Credential	:
Telephone Number	:	773-761-7171

Provider Enumeration Date	:	09/19/2006
Last Update Date	:	12/09/2019

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