Provider Demographics
NPI:1083900195
Name:POLINOVSKY, PAVEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PAVEL
Middle Name:
Last Name:POLINOVSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N ST CLAIR ST
Mailing Address - Street 2:STE 20-100 GALTER PAVILION
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:312-695-1920
Mailing Address - Fax:312-695-5747
Practice Address - Street 1:675 N ST CLAIR ST
Practice Address - Street 2:STE 20-100 GALTER PAVILION
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-1920
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004046363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400187717OtherMEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)