Provider Demographics
NPI:1598931198
Name:LARISSA BERESTENKO MD SC
Entity Type:Organization
Organization Name:LARISSA BERESTENKO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERESTENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-271-9786
Mailing Address - Street 1:2760 WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2631
Mailing Address - Country:US
Mailing Address - Phone:773-271-9786
Mailing Address - Fax:773-271-8028
Practice Address - Street 1:5140 N CALIFORNIA AVE STE 755
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7065
Practice Address - Country:US
Practice Address - Phone:773-271-9786
Practice Address - Fax:773-217-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101565261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care