Provider Demographics
NPI:1477553188
Name:APPLEBAUM, ROBERT ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ETHAN
Last Name:APPLEBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:
Other - Last Name:APPLEBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:2310 YORK ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2411
Practice Address - Country:US
Practice Address - Phone:708-371-2057
Practice Address - Fax:708-371-4569
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074981208G00000X
IN01035864A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200269990CMedicaid
IN200269990DMedicaid
IL036074981Medicaid
IL01618941OtherBCBS
IN200269990AMedicaid
IN200269990EMedicaid
IN408430RMedicare PIN
ILC48877Medicare UPIN
IN200269990CMedicaid
IN200269990DMedicaid
ILK17109Medicare PIN
ILK17108Medicare PIN