Provider Demographics
NPI:1578634168
Name:A PODOLSKIY MD SC
Entity Type:Organization
Organization Name:A PODOLSKIY MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:PODOLSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-918-0430
Mailing Address - Street 1:PO BOX 5979
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-5979
Mailing Address - Country:US
Mailing Address - Phone:847-918-0430
Mailing Address - Fax:
Practice Address - Street 1:755 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 164
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3253
Practice Address - Country:US
Practice Address - Phone:847-918-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111753Medicaid
IL213766Medicare PIN
ILK28521Medicare ID - Type Unspecified
ILI18369Medicare UPIN