Provider Demographics
NPI:1487857421
Name:ANDREW IVANCHENKO MD PC
Entity Type:Organization
Organization Name:ANDREW IVANCHENKO MD PC
Other - Org Name:ANDREW IVANCHENKO MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:OLESYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-630-8340
Mailing Address - Street 1:235 MORAINE RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1933
Mailing Address - Country:US
Mailing Address - Phone:847-681-1161
Mailing Address - Fax:847-681-1171
Practice Address - Street 1:985 S. BUFFALO GROVE ROAD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089
Practice Address - Country:US
Practice Address - Phone:847-681-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI29803Medicare UPIN
IL211684Medicare ID - Type Unspecified