Basic Information
| Provider Information | |||||||||
| NPI: | 1235123589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEVLYAGIN | ||||||||
| FirstName: | SERGEI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ATKINSON RD | ||||||||
| Address2: | STE 207 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600307801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475489777 | ||||||||
| FaxNumber: | 8475489797 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N ATKINSON RD | ||||||||
| Address2: | STE 207 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600307801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475489777 | ||||||||
| FaxNumber: | 8475489797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-100102 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03697846 | 05 | IL | MEDICAID |