Basic Information
| Provider Information | |||||||||
| NPI: | 1437231081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRIZIN | ||||||||
| FirstName: | MIKHAIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16764 W CHERRYWOOD LN | ||||||||
| Address2: | |||||||||
| City: | WADSWORTH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473952389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 909 E PALATINE RD | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600745551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477761400 | ||||||||
| FaxNumber: | 8477761424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 02/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036069643 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036069643 | 05 | IL | MEDICAID |