Provider Demographics
NPI: | 1144225319 |
---|---|
Name: | SANOFSKY, STEPHEN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | STEPHEN |
Middle Name: | |
Last Name: | SANOFSKY |
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: | 2001 BUTTERFIELD RD |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | DOWNERS GROVE |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60515-1050 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 630-322-9126 |
Mailing Address - Fax: | 630-995-7965 |
Practice Address - Street 1: | 2001 BUTTERFIELD RD |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | DOWNERS GROVE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60515-1050 |
Practice Address - Country: | US |
Practice Address - Phone: | 630-322-9126 |
Practice Address - Fax: | 630-995-7965 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-06-15 |
Last Update Date: | 2018-10-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 35063661 | 174400000X |
IL | 036114542 | 202K00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 202K00000X | Allopathic & Osteopathic Physicians | Phlebology | |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0894680 | Medicaid | |
OH | 0894680 | Medicaid | |
IL | F400139974 | Medicare PIN | |
OH | E17578 | Medicare UPIN |