Basic Information
| Provider Information | |||||||||
| NPI: | 1154974590 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSIPOVA SURGICAL SERVICE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1S376 SUMMIT AVE STE 4C | ||||||||
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| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601813966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304241122 | ||||||||
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| Practice Location | |||||||||
| Address1: | 331 W SURF ST STE 714 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606577227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735617911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2019 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | OSIPOVA | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7735617911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086X0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
No ID Information.