Provider Demographics
NPI:1619123171
Name:BORISOVSKY, OLGA L (PHD)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:L
Last Name:BORISOVSKY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 W HARRISON STREET
Mailing Address - Street 2:T12438W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-947-3272
Mailing Address - Fax:
Practice Address - Street 1:1620 W HARRISON STREET, CHICAGO IL
Practice Address - Street 2:T12438W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-947-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-003275OtherPHYSICIAN ASSISTANT LICENSE