Provider Demographics
NPI:1346232493
Name:POLYCHRONOPOULOS, SOTERIOS G (MD)
Entity Type:Individual
Prefix:
First Name:SOTERIOS
Middle Name:G
Last Name:POLYCHRONOPOULOS
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 1:11638 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643
Mailing Address - Country:US
Mailing Address - Phone:773-445-2422
Mailing Address - Fax:773-445-5182
Practice Address - Street 1:11638 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:773-445-2422
Practice Address - Fax:773-445-5182
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051757207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051757Medicaid
IL110019213OtherRR
IL31602250OtherBC-BS
IL110019213OtherRR
D13237Medicare UPIN