Basic Information
| Provider Information | |||||||||
| NPI: | 1871605857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGE R SOSENKO MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3825 HIGHLAND AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307259700 | ||||||||
| FaxNumber: | 6307259703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOSENKO | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 6307259700 | ||||||||
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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 | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 631009 | 01 | IL | ADVOCATE HLTH PARTNERS ID | OTHER | 31600099 | 01 | IL | BCBS PROVIDER ID | OTHER | DE1854 | 01 | IL | RAILROAD MEDICARE | OTHER | 75770 | 01 | IL | ADVOCATE HLTH PARTNERS | OTHER |