Provider Demographics
NPI:1407143605
Name:MAXIM BANKEVICH
Entity Type:Organization
Organization Name:MAXIM BANKEVICH
Other - Org Name:IMDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-215-5099
Mailing Address - Street 1:340 PORTWINE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3831
Mailing Address - Country:US
Mailing Address - Phone:847-215-5099
Mailing Address - Fax:847-999-0478
Practice Address - Street 1:4235 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3573
Practice Address - Country:US
Practice Address - Phone:847-215-5099
Practice Address - Fax:847-999-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid