Provider Demographics
NPI:1083943443
Name:VARDANYAN, ZARUHI (MD)
Entity Type:Individual
Prefix:
First Name:ZARUHI
Middle Name:
Last Name:VARDANYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ZARUHI
Other - Middle Name:
Other - Last Name:MIKAYELYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE
Mailing Address - Street 2:SUITE 1630
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-5869
Practice Address - Fax:708-923-5859
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.129532207R00000X
IL036129532208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400370648OtherMEDICARE PTAN
IL036129532Medicaid
0D16150251Medicare PIN