Provider Demographics
NPI:1124028584
Name:CHASANOV, MAXIM A (MD)
Entity Type:Individual
Prefix:
First Name:MAXIM
Middle Name:A
Last Name:CHASANOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 MOON LAKE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-5029
Mailing Address - Country:US
Mailing Address - Phone:847-755-8090
Mailing Address - Fax:847-843-7393
Practice Address - Street 1:1786 MOON LAKE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-5029
Practice Address - Country:US
Practice Address - Phone:847-755-8090
Practice Address - Fax:847-843-7393
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360848742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084874Medicaid
IL1606781OtherBLUE CROSS/BLUE SHIELD
IL211221Medicare Oscar/Certification
IL036084874Medicaid