Provider Demographics
NPI:1558366591
Name:CVENGROS, TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:CVENGROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N HARBOR DR
Mailing Address - Street 2:APT 4708
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7540
Mailing Address - Country:US
Mailing Address - Phone:312-946-8847
Mailing Address - Fax:312-946-8704
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:STE G2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6163
Practice Address - Country:US
Practice Address - Phone:773-755-2600
Practice Address - Fax:773-880-0403
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093515207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG53861Medicare UPIN