Provider Demographics
NPI:1316044837
Name:EVASKUS AND HERZOG, LTD
Entity Type:Organization
Organization Name:EVASKUS AND HERZOG, LTD
Other - Org Name:ORAL SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PIETRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-761-7171
Mailing Address - Street 1:2440 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4113
Mailing Address - Country:US
Mailing Address - Phone:773-761-7171
Mailing Address - Fax:773-761-6714
Practice Address - Street 1:2440 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4113
Practice Address - Country:US
Practice Address - Phone:773-761-7171
Practice Address - Fax:773-761-6714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600030371223S0112X
204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL527100Medicare PIN