Provider Demographics
NPI:1205835287
Name:YAROSHEVSKY, SEVERYN (MD)
Entity Type:Individual
Prefix:
First Name:SEVERYN
Middle Name:
Last Name:YAROSHEVSKY
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 1:611 S. WELLS STREET #2701
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4782
Mailing Address - Country:US
Mailing Address - Phone:312-493-1219
Mailing Address - Fax:
Practice Address - Street 1:8012 S CRANDON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-731-9000
Practice Address - Fax:773-731-9622
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110134Medicaid
ILI 17818Medicare UPIN