Provider Demographics
NPI:1003996299
Name:PAVLOVSKY, STANISLAV I (MD PHD)
Entity Type:Individual
Prefix:
First Name:STANISLAV
Middle Name:I
Last Name:PAVLOVSKY
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W DUNDEE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4055
Mailing Address - Country:US
Mailing Address - Phone:847-818-7700
Mailing Address - Fax:847-818-1718
Practice Address - Street 1:1401 W DUNDEE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-4055
Practice Address - Country:US
Practice Address - Phone:847-818-7700
Practice Address - Fax:847-818-1718
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360983162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098316Medicaid
IL0021623087OtherBCBS
IL0021623087OtherBCBS
G82528Medicare UPIN