Basic Information
| Provider Information | |||||||||
| NPI: | 1073591533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DREZNIN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4309 W MEDICAL CENTER DR STE A102 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157594323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2338 IMMOKALEE RD # 186 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341101445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393302933 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 168449-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208M00000X | 036132060 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | ME147800 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036132060 | 01 | IL | STATE LICENSE | OTHER | 390006590 | 01 | NY | RAILROAD MEDICARE | OTHER | 01420240 | 05 | NY | MEDICAID |