Provider Demographics
NPI:1790782613
Name:IVANOV, RADA (MD)
Entity Type:Individual
Prefix:DR
First Name:RADA
Middle Name:
Last Name:IVANOV
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 1:5600 W ADDISON ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4401
Mailing Address - Country:US
Mailing Address - Phone:773-481-1570
Mailing Address - Fax:773-481-0547
Practice Address - Street 1:5600 W ADDISON ST
Practice Address - Street 2:SUITE 304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4401
Practice Address - Country:US
Practice Address - Phone:773-481-1570
Practice Address - Fax:773-481-0547
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089071207RC0200X, 207RP1001X
GUM-2341207RP1001X
IN01085124A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089071Medicaid
IL04645032OtherECFMG
IL036089071Medicaid
ILF93100Medicare UPIN