Provider Demographics
NPI:1437169646
Name:ATKINSON CLINIC SC
Entity Type:Organization
Organization Name:ATKINSON CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEVLYAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-548-9777
Mailing Address - Street 1:100 N ATKINSON RD STE 207
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7804
Mailing Address - Country:US
Mailing Address - Phone:847-548-9777
Mailing Address - Fax:847-548-9797
Practice Address - Street 1:100 N ATKINSON RD STE 207
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7804
Practice Address - Country:US
Practice Address - Phone:847-548-9777
Practice Address - Fax:847-548-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036978646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110224169OtherRAIL ROAD MEDICARE
IL4927894OtherBLUE CROSS/SHIELD
IL036978646Medicaid
IL110224169OtherRAIL ROAD MEDICARE